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.

The New Healthcare Team

I've noticed that a few of my Physician Assistant colleagues are worried that physicians are losing their interest in working as part of a team. This is a reasonable worry. Since the formation of the PA profession, PAs have long stated that healthcare is best delivered with a physician-led, team-based approach. With potentially declining physician support for this team-based approach to healthcare, the PA profession may be at risk. I do not feel this trend is present; I believe that utilizing a team-based approach to healthcare will actually become more popular, culminating with the inclusion of the patient as the newest member of the patient-centered healthcare team.

Although formal research is sadly lacking in describing the benefits of physician-PA teams, literature on the subject is not completely missing. For example, the American Academy of Family Physicians (AAFP) and the American Academy of Physician Assistants (AAPA) recently released a detailed report describing the important role of physician-PA teams. The report is very supportive of physician-PA teams, and stresses that advances in medicine ought to focus on developing this relationship, not dissolving it. Even more recently, the AOA (the governing body of osteopathic physicians) released a very similar statement with the AAPA regarding the same issues. Finally, the AMA has a short statement supporting physician-led, team-based healthcare. Although there may be some physicians that do not prefer team-based healthcare--or perhaps even disagree with it--several major medical academies support the notion. 

Perhaps a more important factor to consider is simply that the idea of a healthcare team has not been around long enough to make a clear impact. In fact, PAs themselves have only been around for 50 years. For the first several years after a new profession is created, that profession remains fairly unknown. As with many other new health professions, PAs were (and still are!) fairly unknown. I spend a substantial portion of my introduction describing to my patients what a PA is, and how we are different from physicians, but still provide high quality medical care. But, popularity and support grow with time. Consider the practice of osteopathic physicians (DOs): it took nearly 100 years before DOs were commonly seen in medicine, and it wasn't until 1969 that the American Medical Association granted DOs the privilege to practice medicine legally in the United States. It is possible that the PA profession is on the cusp of reaching that critical mass that will push them into the public spotlight. If we double the short 50 year history of the PA profession, PAs will be seen to play a much greater role in healthcare delivery. PAs will become much more prevalent in medicine, much like our DO partners. 

But the proof of PA success is in the pudding: statistics supporting PA growth are almost impossible to avoid. Forbes, Money and several other magazines have all published articles detailing the incredible growing need for PAs and how PA degrees are some of the best Master's degree to obtain. Furthermore, in two recent polls of physicians, PAs were found to be the preferred professional to work with when delivering healthcare (and the June 2013 issue of The Hospitalist). The evidence is in, and not only are physicians interested in a team-based approach to medicine, but they prefer to work with PAs.

The final aspect of a proper physician-led, team-based approach to healthcare, such as the ones described in the AAFP and AOA papers, is including the patient as a part of the team. Far too many times have I seen doctors or my colleagues lecture a patient for doing research into their own disease. The patient is almost scolded for researching their own ailment, and bringing in papers that support what they think they have. In a physician-led, team-based approach to medicine that ultimately benefits the patient, the patient should play a central role in their own healthcare. Rather than griping about how patients don't know enough about medicine to help in the decision making process, include them. There is an old adage about medicine: "if you listen carefully, the patient will tell you the diagnosis." I suspect, if a patient feels they have a particular disease, the provider should carefully consider it. The patient's training may not be to that of a physician or PA, but they may be on to something. And, in the worst case, the patient's idea only serves to expand the differential diagnosis. Include your patient as a part of the team. A physician-led, team-based approach to healthcare is nothing without the strongest emphasis on the patient.