Juliet: "What's in a name? That which we call a rose by any other name would smell as sweet."
OK, a show of hands.
Who would prefer we change the name of our profession?
Should it be physician assistant or physician associate? Or something else entirely?
The Case for Physician Assistant
Patients are already confused by what we do. Wouldn't a name change just confuse them even more?
Part of this patient confusion comes from the term assistant. It assumes that we are indeed "assisting" someone; in this case, a doctor.
The term itself would lead one to believe that at some point during their office visit, they should have time with the actual physician for whom the PA is assisting.
As a family practice physician assistant in a rural setting, I usually work alongside other PAs and nurse practitioners. Nowadays, rarely is there a doctor to be found on site. And that is OK; there is always someone available by phone if necessary.
In other words, I rarely "assist" anybody.
But, this, in my opinion, is just semantics. I am proud of what I do as a physician assistant and the quality of service I provide my patients.
When my patients ask, "when am I going to become a doctor," I just smile and explain the millions of reasons why I love my job, why I became a PA and why even if given a free "upgrade" to MD I would never even consider it.
The Case for Physician Associate
The term associate is not absent of ambiguity.
Just look at one of the definitions assigned by Wikipedia:
Associate, a person who is in league with the Mafia but is not treated as a full member, e.g. a corrupt official.
Not that there isn't a bit of a "cool" factor that comes with being likened to the mafia.
I think the big complaint about the term "assistant" is that it comes with a feeling of subservience. In a law firm, an associate is a low-level lawyer. The problem with this is that PAs are not low-level doctors they are something different entirely.
Maybe the main problem is the term "physician"
A physician is at the highest level of the medical field. And therefore, the term should be reserved for just that.
For a comparison take a look at variations of the term Nurse:
- Nurse
- Nurse Practitioner
- Certified Nurses Assistant
- Licensed Vocational Nurse
- Nurse Midwife
- Nurse Anesthesiologist
This professional deviation from the term "nurse" is far removed from the original intention.
Here are some other common medical professions:
- Emergency Medical Technician
- Medical Assistant
- Respiratory therapist
- Psychiatrist
- Psychologist
- Radiologists
- Scrub Tech
- Surgeon
- Physical Therapist
- Occupational Therapist
- Physician
- Doctor
- Dentist
- Dental Hygienist
- Nutritionist
- Social Worker
- Phlebotomist
- Pathologist
Here you see many different qualifiers such as: "therapist," "worker," "tech," "technician" and once again "assistant."
Outside of the medical field are other types of professions that exist alongside another "main" occupation; paralegal comes to mind.
One could make the case then for the term "paramedical" instead of physician assistant, but this is just too confusing. Especially given the closely related term paramedic.
A New Profession:
In all honesty, the physician assistant of 2020 is a lot different from the PA of 1977.
Part of what has happened is that we are coming to terms with the fact that to be an excellent diagnostician in primary care one does not need to attend medical school and complete a residency.
There is a minimum effective dose for primary care, and that is probably the education of a physician assistant.
Of course, while working alongside a physician in a surgical role the term assistant is always appropriate.
So maybe what we need then is an entirely new professional designation?
It is not the "assistant" or "associate" designation we should be concerned about but the term "physician!"
Otherwise, we will always be playing the same game, creating the same patient confusion, and constantly struggling to find our own identity.
Maybe we should take a page from William Shakespeare's Romeo and Juliet and accept that the terms "assistant" and "physician" are two star-crossed lovers.
Juliet: "What's in a name? That which we call a rose by any other name would smell as sweet."
- Stephen
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As nurse I find it insulting and disrespectful when PAs believe they have same qualification as NP. PA are Assistant to providers not providers themselves!
Hello, and thank you for your comment. I first want to ask; what type of practice you work for? It sounds like you have not had a good experience with PAs, and I’m sorry.
I ask because I have been a nurse for 20 years, and my husband is a PA for about 17yrs now. We have had many discussions over the years of NP vs. PA.
PAs are in-fact providers and are indeed just as qualified if not more qualified than an NP. They can diagnose and prescribe medications on their own just as an NP can. They differ on the legality of things. Legally, they are assigned a supervising physician who is responsible for checking in with them and signing off on a percentage of their charts. This requirement varies from state to state, sometimes considerably from organization to organization. The quality of the university program they attended can also significantly have an impact on how well they are prepared to enter the workforce. It can also vary on what type of practice they are in. PAs are used very differently in each specialty. For example, family practice, such as my husband, PAs will often be completely autonomous. On the other hand, in a surgical specialty, there may be tighter strings attached as they are ultimately working under their license, and then the term “assistant” is appropriate. PAs also must recertify by exam every ten years. This test is very comprehensive and broad, covering all of medicine and not just the specialty they happen to be working for.
My husband had a wonderful experience with his first family practice job. He was taken under the wings of several physicians and was provided support and constant feedback for his first year. After that year, he worked closely but autonomously, always having a physician to bounce ideas off of and treatment plans with. He was very well supported. He has gone on to have several jobs, and with each one, he has had variable levels of autonomy depending on his supervising physician. Unfortunately, this is not always the case for new PAs. Often, they get a job with little support and are expected to work independently from the start, and often their supervisor physician is not even on sight. This is a disservice for them, their patients, and the profession itself. Some sites are reluctant to provide for a supervising physician, so they choose to hire an NP to get around this legality. Their college education is also slightly different, as it is more based off of an MD model. PA students take classes alongside medical students and often rotate with them through an overly broad and wide range of specialties.
NPs can diagnose and prescribe as well but are not legally required to have a supervising physician. It is exceedingly rare though that you will see an NP have their own practice and work independently from an MD. Being able to practice legally independently does not make them better, and I would argue sometimes scarier. It really comes down to what education they received and their level of experience. It used to be the case that NPs needed to be nurses first and then went back to school for their NP degree. This is not the case anymore. Many universities have fast-tracked this system, and they go right from their nursing program into a focused specialty NP program without ever being a nurse. Kind of takes the word “Nurse” out of the “Practitioner.” Depending on their rotations and education, they are very “Green” upon graduation.
As an RN, I remember my first year on the job. I can say that I learned how to be a nurse from hands-on experience in the hospital that first year with my assigned mentor at the University of Washington Medical Center. My second job was in oncology, and again, I gained vital on the job training to learn this specialty. I had a great nursing program (Seattle Pacific) and great rotations, but it wasn’t until I was on the job and gained experience did I become a “real nurse.”
Nurses, PAs, and NPs do not get extensive paid residency programs like MDs. However, this is changing, and more residency programs are being created for PAs. I am also aware of some RN programs. Nurses, NPs, and PAs all get a job and hope that it is set up to properly guide and mold us. If any new grad takes a position without knowing how they will be supported in their first year, they should not even consider it and look elsewhere. Often organizations and practices are not aware of the education PAs and NPs have upon graduation and believe they are ready to work autonomously right out of the gates. Again, I will say, this is a disservice for them, their patients, and the profession itself.
I believe this may have been the case you have experienced. Someone you feel does not know what they are doing, and they happen to hold the title of PA. As a nurse, I have had, on many occasions, been “disrespected and insulted” by someone who holds the diagnosis and prescribing rights that I do not have as an RN. I only have my nursing knowledge, experience, and opinions. I would hope I can collaborate with my colleagues (MDs, PAs, NPs, medical assistants) based on these things. I too only ask to be heard, respected, and bring a willingness to collaborate and learn from all my colleagues, including those that do not share my title as RN.
The actions and attitudes you have experienced from working with this one PA at your site should not reflect on all the PAs in the world or the profession. The word “Assistant” in the title Physician Assistant can be misleading if one does not understand the role they play in the medical field or the education and legalities they have.
Respectfully,
Wendy Pasquini RN
I think physician-ish or physician lite would be less confusing to patients.
As a practicing PA for over 24 years I’ve grown tired of this title.
In my home state a work force evaluation published in the last 30 days failed to mention or use the term “PA” or physican assistant once. The terms, MD, DO, and NP were laced thoughout the document.
I do part time work in the field of occupational medicine where for the first time in years the ” doctor only” list is growing by leaps and bounds.
I do believe that if the nursing model produces a “Nurse Practitioner” than the medical model likely produces a Medical Practitioner, not a physician , not a assistant…
Time to bite the bullet and change the name..loose the physician..loose the assistant…choose a title that reflects what we do… Medical Practitioner.. and do it before the state’s health care manpower plan and large employer’s make you irrelevant
Yes! Medical Practitioner is the most perfect change, in my opinion
Hi Jessica, I am not sure I like the term “medical practitioner” as it seems rather vague to me. Did you see the latest list of name change options offered up by the AAPA? They are one for the record books… and not in a good way!
Stephen
I don’t work in the medical field and that being said my comments are based on my actual experience with PA’s. I no longer accept being evaluated by a PA. I believe a more appropriate title might be Medical Aide. Over the course of the last several years my experience with PA’s is as follows:
1) evaluated a skin lesion as a “boil” when in fact it was basal cell carcinoma
2) determined that the severe pain following back surgery was part of the healing process. Turns out it was a large hematoma pressing on the spinal cord requiring immediate emergency surgery
3) prescribed a cardiac drug without evaluating drug interactions thus missing a very severe interaction
4) determined that the severe pain from an implanted spinal stimulator was due to pain med withdrawal when in fact the pain was due to a massive infection requiring the removal of the stimulator followed by several weeks of IV antibiotics.
Now, whenever I make an appointment with a doctor I make it perfectly clear that I want nothing to do with a PA other than taking my vitals I.e. blood pressure, temperature and pulse. If that is not acceptable I simply go to someone else. I also believe that PA should have to carry their own malpractice insurance. Once it becomes public knowledge how many patients they actually kill I think we will finally start to see the PA come under more stringent control.
I could not agree with you more. I recently had an appointment with my pcp and a physician assistant came in to go over my medical history. As I was explaining my history with chronic kidney disease she had this blank look on her face. So I asked her a few basic question specific to kidney disease such as pauci immune, The difference between PANCA and C-ANCA, creatinine clearance and GFR and she had no clue about what I was asking. Instead of admitting she had no clue she tried to BS me.
The real problem is that they don’t know what they don’t know. I only hope that people wise up and demand to see a real doctor. Once the law suits start hitting I believe things will change.
Impala,
It is tough to hear that any patient has had the kind of experiences you had when a PA was unable for whatever reason to provide the care you obviously needed…and deserve. I have worked in primary care as a PA for 20 years and, like everyone else I know, have had things slip by…things I should not have missed. There are a couple different kinds of errors that we make. One is that we simply misinterpret, or do not get enough, information. Another is failing to get “another set of eyes”, as the phrase is often used.
A couple points are important here. First…no one…NO ONE…knows everything about everything. I’ve worked with many different clinicians over the years and I’ve seen physicians as well as associate clinicians flummoxed by what others in the same office could diagnosis within minutes (I’ve been on both sides). Some physicians I’ve worked with are uncomfortable with almost any orthopedic injury and refer many more than probably need to be. We all have our own strong, weak, and, unfortunately, blind spots. And in this case I mean all clinicians.
In addition…everyone…EVERYONE…asks for help. Some more than others – depending on experience, training, and type of practice. Physicians at the top of the food chain in their specialty certainly ask less…although an Orthopedic surgeon who specializes in hand surgery may still need some tips from a colleague when called on to manage a giant cell tumor of bone in a 20 year old.
One more thought…my own experience. My MD, who I think the world of, missed the increasingly obvious signs/symptoms of progressive cervical myelopathy. I had surgery within two weeks of the MRI, although that wasn’t done until I had symptoms for over a year. Some of my symptoms did not resolve after surgery.
However I stayed with that MD until she left the practice. I now see an NP as my PCP. She may not have the years of experience (I count years that include practice and education so I think there’s no question that physicians have an education that NP/PA’s cannot match…and don’t need to) but I trust her to do the right thing.
I don’t think I would’ve trusted my clinician(s) after what you went through. But I think you are making judgements both about physicians and associate clinicians that, while understandable, may not completely reflect the wide mosaic of physicians and associate clinicians that function daily as “healthcare providers”…which is what I am everyday – and now for 20 years.
Again, I am very sorry you had such suboptimal care from the healthcare providers who treated you.
Jeff
Greenfield, MA
This article is basically a slap in the face to any Primary Care Physician who comes into work intending to do his or her job well. I am a resident at a top U.S. medical center that hires top ancillary staff so I am very well aware of Physician Assistant knowledge and capabilities. Your premise that you do not need to attend medical school and residency to be an excellent diagnostician exposes your arrogance. While it’s true that four years or medical school and three years of FM/IM residency is a lot, the medical model will always be the superior model and should always carry ultimate responsibility for patients. While PAs are taught basic science and can access resources to learn the zebras, they simply aren’t tested on it to the level an MD/DO is. When it comes to clinical education, emphasis is always on presentation of patients and getting consults from other providers by acting like a broken record “my attending wants it”. In the primary care setting, there is no investigation into the primary cause. Yes, diabetes and hypertension are the common causes of CKD, but if the patient is leaking protein for months with a lower GFR, you better do a further work up into the other causes. PAs routinely miss this because they of the attitude that “medicine is not complicated” and the fact that they view their job as a 9-5 with no obligation for continual education.
Before you start worrying about the term physician, why don’t you instill moral accountability into your trainees and let them leave only when the job is done instead of having them dump all their unfinished business on residents? How about you make them write notes that make sense and be interpretable by other medical providers instead of ones that look like they’re written by broken speech recognition software? How about you hold them to higher standards in terms of actually having them compete with physicians regarding medical knowledge because the PANCE is a joke? How about you instill a culture of continual self directed learning instead of training your future profession to view medicine as not that complicated that can be 9-5’ed? I know…because at the end of the day, you think deep down that physicians are stupid and your way is better, but when push comes to shove you just push buttons, don’t think, and think that physicians will clean up your mess. If you want to practice independently why don’t you learn actual medicine and instead learn to manage patients instead of presenting them? How about you take accountability for your errors? Oh wait, if you do that, you’re going to be in school longer, working from 6am-7pm with weekends when you’re out. I’m not even a primary care physician but I make it a point to have every one of my patients see an actual MD/DO when I see PA-C or CNP under the PCP designation.
This response is extremely arrogant. No where in this article did anyone claim physicians are stupid. It is because of people like you that PAs want a name change in the first place- they don’t want to be seen as YOUR assistant. PAs work incredibly hard and DO follow the medical model in the accelerated 2-3 years of graduate school. How about instead of bashing on them for wanting respect you instead learn to respect all those in the medical profession because nothing would get done without each and every one of them. You do not walk on water sir and you most certainly don’t have the right to insult on your fellow healthcare professionals.
I could not agree with you more. With regards to the PANCE test, I took a 100 question sample test and scored in the high 70’s and I have no medical background other than what I have learned managing my own health.
You sound like a overworked medical resident who might be regretting their own career choices. I’m a PA working in a higher acuity urgent care (we have RNs, CT, US, x-ray, do labs, IVs and procedures and function like the fast track of an ED) and work with PAs, NPs and family practice docs. Several of our docs are in their first job out of residency. ALL of our PAs have ED experience and a lot of us have 10, 15 or even 20+ years experience working in medicine. We can trade shifts with each other and are completely interchangeable, no difference in our jobs and responsibilities whatsoever. In this particular situation, we function completely as equals. However, a patient is much more likely to be referred to the ED for a simple lac, given antibiotics for a common cold or get unnecessary CYA testing by the doc. I’ve had one of these new docs ask me to see a possible eye FB patient because they’re just “not comfortable” with eye problems. I’ve seen another one send a nurse maids elbow to the ED. I regularly see their abscess or paronychia patients return because they were only treated with abx by a doc who didn’t want to do the I&D. On the other hand, I’ve worked in EDs with docs who I absolutely look up to and defer to and consider mentors and teachers. My point is, there’s variations in all professions. You can see and inept doctor or an inept PA. You could see a PA with 15 years of experience (On top of graduate school and undergrad and previous healthcare experience) or an MD who just finished a 3 year residency (on top of med school and undergrad, etc). Why don’t you try supporting and respecting all of your colleagues regardless of their specific background and education. Everyone has things they could learn and improve on and everyone has something to bring to the table.
The US Department of State uses the term Medical Provider (FSMP or foreign service medical provider) which is pretty much identical to “medical practitioner”. And yes it is broad and encompasses PAs and NPs. When you think about it, ALL healthcare professionals provide medical care.
I don’t think the word “physician” is the problem as long as it has a prefix/suffix to indicate we are different from MDs and DOs. Patients seem to understand doctor, doc, physician, etc. to mean “the person ultimately taking care of me”, and I find that patients will continue to call me (doctor, etc) even after correcting them and clearly explaining what a PA is. I have seen this with NPs as well. Patients will see you as the “doctor” if you are the one ultimately taking care of them, regardless of what your title is and the explanation you give them. And so the confusion arises when the “doc, or person taking care of them”, is wearing a name tag with the word “Assistant” in the title. In my opinion, Physician Associate may not be perfect, but probably best. The word “associate” may be ambiguous, but at least it is not misleading like the word “assistant”. No profession will have the perfect title; the title “doctor” is actually quit ambiguous as well. And NPs have it even worse! I think the term “Physician Associate” removes confusion and allows some room for the continuous evolution of our profession.
The only problem is that I am going to have to rename my website 🙂 But, the general consensus seems to be in agreement with your sentiments!
Stephen
Most days I don’t have time to explain what a Physician Assistant is to my patients in a busy Urgent Care setting. Oftentimes, I will describe my profession as “similar to a Nurse Practitioner” to move the conversation forward. Physician Assistant does not do our profession justice as for most of us don’t just “assist” but practice medicine! Physician Associate, Medical Practitioner, anything but Assistant. This is a topic that needs to be addressed by our governing officials then voted on by the PA profession.
Hi Luke,
I used to disagree, and felt that a name change would just confuse our patients even more. But given how often people ask me “when are you going to go back to school and “go all the way”” I am realizing that maybe you (and the AAPA) are right and the term “assist” is a problem. Nobody asks the nurse, or the radiology tech, or the anesthetist or really anybody else with a health professional degree that questions. People do ask medical assistants that questions though, and we share a part of our name in common. The AAPA has proposed that we are just “PAs”, kind of like and RN except the acronym would have no real meaning. The other part of the problem is that we use the word “physician” and as long as that is part of our title we will always be in some way “less” or in “search” of something “more”. In the UK PAs are called physician associates, but I am not sure I am a fan of that either.
Thanks for sharing your thoughts on the topic.
Stephen
Stephen,
The AAPA proposal for just “PAs” is the most ambiguous term yet. Try to think of an acronym in English today that has no meaning behind it, exactly, they are none! I’m not saying Physician Associate is the perfect term, but it is less misleading and more representative of the education, responsibility, and skill level required to function as a PA. I think you would be surprised to see how many PAs in training/practicing want a name change and I think this needs to be at the top of AAPA discussions. AAPA needs to obtain a list then defer the issue to a nation wide vote of physician assistant constituents. In the mean time, I may discuss with the UK PAs on how they are perceived and give you feedback.
I agree completely about the acronym PA – seems like it is being used more as a “placeholder” until there is some consensus. I think you are on the right track regarding discussing this issue with those working in the UK.. I am eager to hear your findings. Now if we could just model our healthcare in a similar universal fashion we would be making real progress.
Stephen
I’m an ICU RN advancing my education as either a Nurse Anesthetist or a Physician Assistant. I found this article to be extremely compelling and worth further investigation. Has the PA profession ever considered the term Medical Practioner? Nurse Practitioners, advanced practice nurses with either a Master’s or Doctorate degree study the nursing model of care, Physician Assistant’s study the medical model of career and perhaps should be called Medical Practitioners.
Hi Michael,
I think you hit the nail on the head, if a problem does indeed exist, it isn’t with the word “assistant” it is with the word “physician”. I personally think “medical practitioner” is a bit too broad and all encompassing, but then again, I am more than happy to keep our current name mostly because it now has recognition and I believe that as practitioners we are judged far more often by our actions than by our namesake.
– Stephen
The best term I have heard for the profession is “Paraphysician” as the term was originally used long ago. If you look up the definition of what is a paraprofessional, the term is more appropriate today now more than ever.
Too many are confusing Physician Assistants with Medical Assistants as a Paraphysician can have a it’s own level of ability in the public’s eye such as a paralegal in law or a paramedic. See the wikipedia listing for Physician Assistants as the industry is moving towards the title of “Paraphysicians.” For details see: https://en.wikipedia.org/wiki/Physician_assistant
or http://brunerfoundation.org/BFhistory.html