The Medical Hierarchy

Over this past weekend, I volunteered at a small local farmers' market, if for no other reason than that I enjoy farmers' markets and wanted a good reason to be there. I set up a small booth and tried to engage people in conversation geared towards health. After a few short conversations about childhood obesity, hypertension and diabetes, I met a nice older gentleman who was a professor at one of the nearby colleges. He was unfamiliar with Physician Assistants, so we spoke of the usual stuff: what PAs are, what we do, and how we're different from our doctor counterparts. He was particularly interested in if there is a medical hierarchy, as there is in academia.

This is a good question.

In academia, the basics of a certain speciality are learned after four years of university education, with the student earning a Bachelor's degree. Further education leading to advanced mastery of the subject can be obtained, culminating with the production of original research and the conferring of a Master's degree. Finally, for deep specialization in a small subsection of that specialty, a Doctorate can be earned, representing the highest degree in academia.

To dramatically simplify the role of each level of education, consider the way level of education typically works: Bachelor degree holders work under Master degree holders who work under Doctorate degree holders.

Of course, medicine is a specialty within academics, and as such, it logically should follow the above hierarchy, at least in some sense. For example, nurses (with a bachelor degree) work under PAs (with a Master's degree) who in turn work under physicians (with a doctorate degree).

And in many clinics that I've seen, this is the way medicine is practiced. It follows a very rigid hierarchy, with PAs landing somewhere in the middle (hence the awful term "midlevel"). But medicine does not need to be this way. In fact, medicine shouldn't be practiced this way.

With an advanced mastery of medicine, PAs are highly equipped to deal with most medical problems, ranging from general medical issues to complicated surgical issues. A PA's training and skill set is far beyond that of a "mid-level" provider. Some reports have even suggested that the care given by a PA is similar to that of the care given by a physician (albeit more research is desperately needed in this area.) In my ER practice, PAs manage stroke patients just as much as the doctors. Does this sound like the PA is practicing as a "midlevel" provider?

More importantly, in the above hierarchy, the PA's autonomy is lost. When the PA is constantly supervised and overshadowed by an attending, it is a waste of time for both providers. A patient typically does not need two sets of expert eyes. Having an autonomous PA is what makes the profession so powerful; PAs are able to see patients in addition to the physician, not with the physician. Although it is important to practice in a physician-led, team-based approach to healthcare, this in no way implies that the PA should be limited in their scope of practice. The PA should be allowed to practice to the highest level of their training, which indeed, is very high.

Now, that's not to say that physicians don't have their place. For extremely complicated patients requiring detailed and advanced interventions, having a medical provider with a corresponding extremely high level of training is necessary. This level of training is not needed for most patients, but it sure is needed in some cases and cannot (and should not) be forgotten.

So, what did I tell the professor at the farmer's market? That although medicine does sometimes use a hierarchy, it more frequently is harmful to a practice than helpful. PAs ought to be utilized to their maximum, as all medical professionals should be. A more practical and beneficial work organization is one that has PAs, NPs, and doctors all working collaboratively, using each other as needed so that more patients may be seen by more high-quality providers.