by Vera Mehta, Ed. D. | November 2001
What exactly is a Physician Assistant? How is his/her role different from that of a doctor or nurse? What kind of training does a PA get? Who are the Physician Assistants in our office? What kind of experiences have they had before coming here? How do they view their experience here? How do patients feel about seeing PAs?
These questions and others like them have come up many times since Drs. Yaffe and Ruden hired their very first Physician Assistant way back in 1989. Today we have seven Physician Assistants who have become indispensable to our practice. Most of our patients are quite accustomed to the system and feel comfortable with the idea that a competent person will see them first to do the initial paper work and exam as long as they know that a doctor is also going to come in afterwards to go over the treatment plan and answer any other questions they may have. However, even longtime patients are sometimes not sure of the credentials of a PA and express their doubts in the form of questions such as, “Well why do I have to see the Physician Assistant when Dr.____________ has been my doctor for X amount of years. Or, “________ doesn’t know anything about my medical history so why can’t I just see my doctor straightaway instead of having to sit here and start all over again with someone who’s not even a doctor?” The secretaries who answer the phones and make appointments are the ones who get bombarded the most with these kinds of questions. They do their best with trying to provide satisfactory answers while juggling eight phone lines. Not always an easy task.
I decided to interview the Physician Assistants in our office both to enlighten myself about some of the gaps in my own knowledge and because I thought it would be beneficial for patients to gain a clearer understanding of their role in assisting the doctors and participating in the overall care of patients. I also felt it would be interesting to see how their perspectives would differ, since although they all work in the same office, and are all very skilled and competent at what they do, they are still all unique individuals with their own individual histories and temperaments that must in some way impact upon the way they see patients and vice versa. As someone who has answered the phone in this office for years, I have become used to patients who are familiar with our system, asking if they can be put in the schedule with their “favorite” PA. I am curious to know what those attributes are that make patients comfortable with a particular PA or whether the “culture” of our office generates a particular type of interaction that patients have come to recognize as part of a Yaffe/Ruden composite persona.
“Interviewing” our Physician Assistants while at work turned out to be easier said than done. As all our patients know, this is a very busy office. So while all our PAs (the 2 new ones were only hired very recently) were very gracious and eager to assist me in my educational” mission for the Chronicles, it was not easy to find time when anyone was actually free to spend even five minutes answering my questions. Well, if one wants to collect data in “natural” settings, the first thing one learns is to be adaptable. I decided to give each PA who agreed to participate, a short questionnaire to take home and answer at leisure. I figured that would give me at least a basic starting point and then, if I wanted more clarification on anything, I could always follow up in a later conversation
Valerie received her Physician Assistant’s degree in August 1997 from SUNY Health Science Center in Brooklyn. From December 1997 through January 1998, she worked with our office while it was still at the 84th Street location. (This was to cover for Dr. Heather Canning in the weeks that she had gone on home leave to Australia.). Immediately after she left our office she went to work for New York Hospital Medical Center of Queens. There she was involved with preoperative evaluations. She assisted in the O.R, did saphenous vein harvesting, post-op care in the ICU and got experience in the step-down and telemetry units. After we moved to our present location at 201 East 65th Street, Valerie came back to work with us in June 1999.
Darryl trained at Stony Brook University from where he received his degree in 1987. He has worked in many different settings ranging from in-patient care where he was directly involved in caring for geriatric rehab patients to an urban clinic setting where patients would present with a multitude of varied illnesses. In 1983 Darryl went through a 12-week pre-medical program at the Ohio Osteopathic Medical School. He joined our practice in 1995.
Geri attended the Long Island University/Brooklyn Hospital PA program from where she received a B.S. degree in 1994. After graduating from the program she worked at a Brooklyn Emergency Medical Center for 5 years seeing both adults and children. She joined Yaffe/Ruden and Associates in 1998.
Lauren graduated from the University of Michigan with a Bachelor of Arts Degree in Psychology in 1997. She completed the Physician Assistant Program at Touro College in the year 2000. After graduating from the program, Lauren worked as a PA at a private, plastic surgery office in Manhattan for 6 months assisting with various surgical procedures. However, Lauren felt she was not being challenged enough. She was not making diagnoses or treating illness. Nor was she getting an opportunity to put the knowledge and skills she had acquired in the PA program, into practice. That was why when the opportunity arose to work in the Yaffe/Ruden practice, she gladly took it.
QUESTIONS AND RESPONSES
Question 1. What IS a Physician’s Assistant? How is it different from being a doctor, nurse/nurse practitioner?
A Physician Assistant is a mid-level healthcare provider who needs to work under a supervising physician. The physician does not need to be present while the PA sees patients. It is similar training to an M.D in that you have the didactic phase, the first one and a half years where you take courses like gross anatomy, microbiology, physiology, medicine etc. The second part consists of rotations (much like that of a 3rd/4th-year med. student). You do 6-week rotations of ob/gyn, medicine, surgery, pediatrics, psychology, geriatrics, etc
Its different from an M.D. in that it is not as long and you are NOT required to do a residency-although there are some one-year residency programs in the U.S.
It is similar to a Nurse Practitioner in that they are both midlevel healthcare providers, but NPs are nurses prior to entering the NP program-the training is more from a nursing perspective and they are allowed to have their own practice.
PAs are mid-level practitioners who are trained to fit the niche between nurses and physicians
A PA is a medical professional, who sees and evaluates patients, prescribes medicine, makes diagnoses. A PA differs from an M.D. by training and education: an M.D. goes to medical school for 4 years plus residency; a PA’s education is 2 years. A PA cannot open their own practice. They must work under the auspices of an M.D./Hospital. The PA does not have to work at the same location as the M.D. All PAs are Board Certified and both [PAs and M.Ds] are responsible for CME (Continuing Medical Education) credits. PAs must take re-certifying exams every 6 years.
A PA is a health care provider who is certified to perform assessments, order diagnostic tests, make diagnoses and treatment plans, and prescribe medicine “under the supervision of a physician”.
Question 2. What made you decide to become a Physician Assistant?
1) Training not as long as an M.D.
2) Hours more flexible to have a family.
3) You can change subspecialties easier than an M.D. (i.e. I was in cardio thoracic surgery before).
Initially I had planned to become a doctor but felt that the time and money required to attain the degree was beyond my means.
I was always fascinated by the human body and love learning about it. I decided to become a PA because I didn’t have to go to school for 8 years (as in M.D. training). I didn’t have to incur medical school debt; I could start working after 2 years. More free time than an M.D.
I have always been interested in medicine, and being a PA allowed me to join the medical profession in fewer years than medical school
Question 3. What was your classroom experience like?
The classroom hours are Monday to Friday, 8AM to 5 or 6PM. They encourage you not to be employed. The two students in my class that did have jobs, failed out.
The training is intense. Typically, a normal day is 12 hours long, consisting of lecture after lecture with very few breaks. The expectation is that each student pass each course with a passing grade of 70 or ultimately be expelled. Many of the modules are similar to those taken by medical students.
The first 12 months is all didactic. Second year you have medical rotations (5 weeks each) in gyn., surgery, internal medicine, emergency medicine, pediatrics, geriatric medicine.
One year didactic (classes), one year rotations
Question 4. How do you see your role in this office
To make the office work more efficiently for the benefit of the patient-patients are able to be seen the same day by a healthcare provider.
I see myself as a facilitator
PAs have a key role in this office. They see all “office visits” and occasionally do physical exams. Having a group of PAs on staff allows patients to be seen when they are sick.
I see myself as a healthcare provider who is qualified to make initial assessments and establish and carry out treatment plans.
Question 5. Do you think patients respond differently to you because of your a) sex, b) age, c) ethnicity or background, d) any other attribute?
The only problem I see is that maybe some patients think I’m too young.
Probably both sex and ethnicity seem to play a role. I feel that, depending on the gender of the patient, I may have to overcompensate to adjust to the patient’s comfort level. Stereotypes for Blacks still affect perceptions and make it more difficult to be effective.
Most patients think I am a doctor or nurse, never a PA. Other patients think I am much younger than I am, so think I am inexperienced.
Sometimes. I am frequently asked my age and told I look very young. A lot of people ask if I’m still in school also.
Question 6. What is the most rewarding part of your experience working in this office?
Continuity. Following up with patients, making difficult diagnoses.
Knowing that in a small way I’ve made a difference in someone’s life.
The most rewarding part of working here is meeting the diverse group of patients.
I get to work with a lot of great people and I can learn a lot from the other PAs and doctors here. Since there is such a variety of patients coming in we see a wide range of medical problems and diseases.
Question 7. What is the most difficult part of your experience working in this office?
When Patients do not understand the role of a PA, or when patients think that a PA is an MA (Medical Assistant) just someone who writes down the problem and checks blood pressure. Also, when patients call a half-hour before and expect to be seen immediately.
This seems to be less of an issue, but it used to be the numbers of patients I had to see. Since the Associates [i.e. the new Associate Physicians] began, the pressure to perform has subsided.
Keeping up with the high volume of patients. Trying to see patients at their scheduled times.
Some days when we are very busy and falling behind, it is difficult to keep the patients happy when they have been waiting for a while.
Question 8. What suggestions can you make to patients about how they can most effectively participate in their own health care and get the most out of a visit to the office?
Patients need to understand that health care has changed. M.Ds don’t spend half an hour to an hour with patients anymore. They have to be aware that there are other participants involved in the healthcare system-PAs, NPs, midwives etc. Don’t be angry-instead, make the most out of your visit and try to develop a rapport with the NP, PA etc. I, for one, know that I use an NP as my GYN.
I would think that the more informed they are in regards to the state of the health care system and the difficulty that practitioners face in terms of balancing providing quality care and maintaining a viable business, would make them more tolerant and give them a better understanding as to why they are being seen by a PA. Our role is to alleviate the pressures that Dr. Yaffe and Dr. Ruden face by evaluating and providing the type of care that they would like to provide for their patients, but, because of the constraints placed on them by insurance companies and HMOs, they must see greater numbers of patients to sustain a reasonable living.
With the amount of information available via the Internet and the level of quality of information that is accessible at certain Websites such as WebMD and MSNBC Health, for example, many of the questions that they may have for us can be addressed without having to see a practitioner.
A way patients can participate in their own health care might be to know what meds they take. Ask questions when they don’t understand clinician’s orders at time of visit.
Patients need to understand that if we are able to fit them in the same day they call they may have to wait a little while to be seen by someone. Patients also need to specify when they make an appointment, who they want to see that day and understand that they may be put in one of the PA’s schedules. We can always get one of the doctors in as well.
Question 9. Is there anything else you want to add?
Drs. Yaffe and Ruden need to use PAs more efficiently. There is no need for an M.D. to go into every room after the patient has been seen by a P.A. especially if the visit is routine-which is 70-80% of our patients.
After reading over the responses above, I am struck both by their similarities and their differences. It comforts me a great deal to realize that all our PAs received very similar training no matter which schools or programs they attended-rigorous, demanding and of a uniformly high standard with exposure to a wide variety of medical specialties. Since I am not familiar with medical systems in other parts of the world, I cannot comment on them. But I CAN say that the attention paid to the training of medical practitioners at many levels besides just Physician/M.D. here in the U.S, is a very creative and effective solution to the problem of providing decent healthcare to an ever-expanding patient population, especially under the current system of Managed Care.
All 4 PAs mentioned being drawn to the medical profession but being intimidated by the expense and amount of time they would need to spend in training and going into practice as an M.D. Becoming a PA seemed to be a very attractive alternative in that it offered the satisfactions and rewards of being part of the service or “helping” professions without the extreme sacrifices that are required to become a successful, practicing physician in our society. I refer especially to the sacrifices of personal and family time which is one of the heaviest prices we pay for what Juliet Schor refers to in her path-breaking book,The Overworked American, as the growth of “long hour jobs” in capitalist economies.
When asked about how each PA viewed his/her role in the office, there are some interesting differences in perspective. Some see themselves as part of a total operation-”helping the office run more smoothly”. Others as conduits of communication between doctor and patient whose goal it is to “facilitate” the recovery of the patient by carrying out a treatment plan that they know the patient’s doctor would approve of.
And, finally, when asked to comment on how patients could make the role of the PA a more productive part of their office experience, their responses ranged from the practical-be prepared with accurate information about the current medications you are taking-to the more generalized. I think they’ve offered some very useful advice re becoming savvier about the many radical changes in the American healthcare system and about not getting angry or impatient because things have changed. As they point out, sometimes expectations have to be altered to deal with those changes because they are not the fault of the medical providers.
A PATIENT’S PERSPECTIVE ON THE PA SYSTEM:
Although this Chronicle has chosen to focus on the PAs’ role at Yaffe, Ruden & Associates, I did not feel it would be complete without getting at least one patient’s perspective on how it is seen from the patient’s point of view. I did not have any person in mind to “interview”-my choice was dictated entirely by constraints on my own time and who happened to be sitting in the waiting room when I had some time to do a short, spontaneous interview, if of course the patient agreed. The only qualification I necessarily had to impose was that it should be an “old” patient, i.e. one who had been coming to our practice for a long time, preferably starting when we were still in the 84th Street office. I was lucky enough to find just such a patient. So while I make no claims that this person is a “representative sample” (to use the jargon of sociological research) since it is only one person, she is still strictly speaking a “random sample”! I will try to use her own words as much as possible in setting down what she told me about her experience with the practice.
G. A. is one of Dr.________’s oldest patients. She says she has been coming to him for almost 18 years. She has been seen by practically every PA in the practice and says that although she was “a little shocked” the first time she called the office for an appointment and was told she would see a PA first, since then, she “does not have any problems” with this system. In fact G. says she has been “really impressed all the way”.
It gets one in and out faster. Let’s face it, we all want to see Dr._______ but we also want to see A doctor and I know he’s on top of it all. If I have any problem, he comes in. I feel as if it’s being watched-I don’t feel like I’m being neglected. This is a way for Dr, ______to see many more patients, but he can still control the situation. And I know I can always see him ultimately. I also know I will see him at least once a year when I come for my yearly physical.
About standard of care:
The medical care here is terrific. There’s that lovely woman from Australia and the gorgeous young Black guy (!) But they’re all great people. Dr._______ knows what his standards are and knows they’re being met. If I feel something is wrong with the care I’m getting, I’m confident I can tell Dr._____ When I was sick with pneumonia, he was on top of the situation, got me into the hospital, told me what to expect, made sure that my care in the hospital was overseen.
The Yaffe/Ruden office environment:
The medical world is changing. In my lifetime I’ve seen a lot of indifferent doctors. But in this office it is still very personalized service. With Dr. ______I don’t only talk about medical issues. We talk about a variety of things and it’s that kind of relationship about a doctor which I appreciate. The environment has always been very human. Quirky, interesting, not sterile on ANY level, intellectually or medically. It’s very humanized medical care, more like a real world situation. I want a doctor I feel confident talking around. I think the PAs reflect the environment the doctors here have created. They are all decent young people learning their profession. What a wonderful opportunity for patients to be part of that process!
On the matter of trust:
It comes down to trust. You have to trust Dr._____ ‘s opinion of who he hires. If you trust Dr.__________ or Dr. ________ to take care of you, then you must trust the people they choose to take care of you.
What can I possibly say after that?