Are Physicians Overtrained? Is Physician Assistant Education Enough?

In last month’s issue of JAAPA (Journal of the American Academy of PAs), PAs James Cawley, Richard Dehn, and Dr. Christine Everett discussed whether or not the educational paradigm for primary care providers is changing, an issue already addressed by physician assistant education. The authors raise the question: Are physicians overtrained for primary care?

PAs Are a Solution to a Real Problem

Most physicians recognize and welcome the contributions of both PAs and NPs. They know all-too-well that there is more than enough work to go around and they don’t feel threatened by clinicians trained under new models of care relieving their workload. That sentiment is not shared by all, however.

“If at first an idea is not absurd, there is no hope for it.” Albert Einstein

It has been disappointing, but not altogether surprising, to receive a few angry and defensive emails here at The PA Doctor. These emails usually come in response to articles suggesting that PAs and NPs are capable of providing care on the same level as physicians. Most of these comments come from fabricated email addresses and under fictitious names. 

Why is a vocal minority so afraid of innovation? Cawley and colleagues suggest that “the very existence of these discussions in high-level medical education circles represents an affirmation of [PA and NP] clinical competence and a rethinking of physician education”. 

Collaboration with physicians is woven into every facet of physician assistant education. Again, most physicians value competent colleagues, but those more clamorous dissenters threaten team-based care.

I hope that among those who oppose advanced practice clinicians do so out of a legitimate concern for patient welfare (although available data fails to support that concern). In my experience working to modernize PA legislation, I regretfully report that too many physicians prefer (or at least tacitly support) policies that are more about controlling competition than protecting patients. 

Rather than shaking fists and writing exasperated emails, legendary business innovator Clayton Christensen suggests that primary care physicians should evolve and market themselves as performing many of the services they now refer to hospitals and specialists.

I don’t think PAs ever intend to replace physicians, however. In fact, the official policy of the American Academy of PAs maintains PAs’ desire to work alongside their MD colleagues. Contrast that with the emphasis on independent and autonomous care endorsed by the American Academy of Nurse Practitioners

The question remains, however: Are physicians over-trained for primary care (a field largely being taken over by non-physician clinicians)? 

A Giant Keeps Growing

Mantosh Dewan, MD and John Norcini, PhD note that primary care physicians actually perform fewer procedures than they are trained to perform. Yet Oregon Health and Sciences University is increasing the duration of their primary care residency from 3 years to 4 years! The pair boldly suggest that even 1 year of postgraduate education is actually unnecessary to practice general medicine.

Dr. Olle ten Cate, PhD, a professor of medical education in The Netherlands also commented on the troubling trend of swelling requirements for physician education. He notes that traditional physician training is nearly twice as long as it was 100 years ago. He then says that: “If the historical trend of doubling the training time within a century is extrapolated, by 2100, physicians-in-training may be en route to retirement before they are fully licensed.” He also notes that many highly specialized physicians train the longest just to perform repetitive tasks. 

Referring to PAs, NPs, and physicians as the 3 medical giants, Drs. Dewan and Norcini state that the “medical education community has not taken on the challenge of defining the training and scope of practice of the shortest physician giant; instead, the focus is more easily on adding requirements and creating the tallest giant.” The state of Missouri, on the other hand, has allowed medical school graduates that didn’t match into residency training to practice primary care in high-need areas as long as they have a collaboration agreement with a residency-trained physician–these clinicians are known as assistant physicians.

Physicians are surely the tallest giant. There is no argument there. But does being the tallest giant consistently produce a better clinician? The entire argument of non-physicians is based on a resounding “no”! 

David and Goliath

I’ve been in practice for almost 10 years. Everything I know and use on a daily basis has been acquired after my formal training. I don’t disagree that a basic foundation was essential but medical education is an ongoing effort–a journey rather than a destination. Studies actually show that medical students forget over half of what they learn from year to year anyway!

Nurse practitioners have lobbied for and won the battle for independent practice in 28 states. Dewan and Norcini refer to NPs as “the shortest giants” citing their ability to practice independently after 6 years of formal education and 27 weeks of supervised practice. PAs also train for 6 years but with 45 weeks of supervised practice (the minimum requirement for medical school grads is 7 years and 65 weeks). 

Dewan and Norcini are very clear about their opinion on PA independence and autonomy: “PAs are taller than the shortest giants and have earned the right to practice independently.” This possibility only comes to fruition when “political considerations are replaced with a purely evidence-based approach”. 

Physician Assistant Education

What does the evidence say about PA practice? Available evidence indicates equivalence in quality measures for patients being treated for depression, diabetes, hypercholesteremia, and HIV in primary care settings. PAs can perform invasive procedures with equivalent outcomes. Studies also indicate that patient satisfaction when treated by PAs is no different than when treated by a physician. NPs also have RCTs supporting some of their claims. 

Clearly, as Cawley suggests in JAAPA, “PA and NP education models are effective and economical approaches for primary care practice”. But this really isn’t new information. By the time PAs were celebrating their 10th birthday in the late 1970s, over 40 studies had been done reviewing the quality of care they provided. What was the result? Harvard-trained physician Harold Sox, Jr., who would later become an editor with several major medical journals, came to the conclusion that “nurse practitioners and physician assistants provide office-based care that is indistinguishable from physician care.” 

PAs celebrated their 50th birthday just a few years ago. Has anything changed regarding the quality of PA care in the interim? Hooker and Cawley in the American Journal of Managed Care report that while PAs trained at one fourth the cost of physicians they were still able to manage a nearly identical scope with results that appear to be “indistinguishable from that of physician-delivered services”.

Collaboration or Confrontation?

This information is apparently quite offensive to some physicians. I can understand that. Getting into medical school is not an easy task. It takes years of prep to even merit an interview. The amount of debt medical students incur is absolutely insane. They also sacrifice some of the best years of their lives to their training. I might also feel insulted if someone claimed that they could do my job just as well with only a fraction of the sacrifice—only to have them claim that I was then overqualified.  

But is continuing to deny the contribution and potential of advanced practice clinicians in the face of empirical evidence the right course of action? Based on a few comments we have received, some seem more committed to self-justification and irrational escalation of commitment. Jack Rowe, MD the former chairman and CEO of Aetna has said: “This is a turf battle in which physicians are threatened over issues relating to professional pride and money.”

Could the same be said of this author? Of course. I envy the experiences of resident physicians as well as the respect and income of the attending. The grass is always greener on the other side. That being said, many physicians have voiced their regret over their chosen career path and some have even confessed in confidence their wish to have attended PA school versus medical school.

In the end, all that matters is taking good care of people and there are no particular credentials that confer that ability. 

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