Post-Graduate Training Programs, White Coats, and "Midlevel Encroachment"
There is no shortage of outrage about midlevels these days, but I feel like there is a gross lack of nuance in most discussions about them. So I wanted to address the newest outrage on the medical subreddits that has cropped up recently over PA post-graduate training programs. The outrage seems to stem from a few areas, including use of the terms “residency” or “fellowship” to describe them, the pay (which in some cases is higher than physician residents), a concern about the impact on physician training (specifically that it causes competition that “steals procedures” from residents), and a fear that these programs are a sign of “midlevel encroachment”. I think most of these fears are unfounded, and the outrage is misguided, though in some cases understandable.
The timing of this outrage is interesting though. Post-graduate training programs for PAs have been around since the early 1970's (before many of those that are angry were even born). The first one was a surgical PA training program started by physicians at Montefiore Medical Center in 1971, which still exists to this day. These programs have used the same terminology since their inception many decades ago, terminology that was applied to them by physicians, not by PAs. Whether that terminology should be changed is a valid debate, but it's use is not without precedent.
The PA profession was designed on an apprenticeship model where a physician would take a new PA under their wing and provide training in their specialty for a period of years while allowing increased autonomy in practice as competence increased and trust developed; this is why PA training is shorter and doesn't require a residency. With more and more physicians employed by health systems, there are fewer and fewer physicians willing to provide this close training relationship. Post-grad training programs serve as a way for PAs to get standardized training in a given specialty, while also serving as a tool to recruit and retain well trained PAs by the hospital systems that fund them. Just like PA education is based on the medical model (which was designed by Dr. Eugene Stead based on his experience with fast-track physician training in WWII), it makes sense that PA post-graduate training would also be modeled after that of physicians.
For hospitals, post-grad PA training programs allow them to offset the training cost they would otherwise incur when hiring new PAs (who are less productive in their first year due to a steep learning curve) in exchange for providing a structured training program. It's also important to note that PAs are already certified and licensed upon starting these programs, meaning they can bill for their services throughout the entire training program, which further increases their value to the hospital.
These programs are not just glorified shadowing, as some have claimed. Many require the same schedule and call requirements as residents (including 24-hour coverage, and night and weekend call hours), and have the same expectations for PAs as they would a PGY-1 intern. Some also follow ACGME guidelines. The major difference, of course, is the end goal -- these programs are designed to increase the competency of PAs to work in specialties the way the profession was designed, on physician-led teams. They are not designed, nor intended, to train independent practitioners. Some other examples for those interested are the programs at Emory, NYU, Johns Hopkins, and Duke.
There have been numerous claims that these programs directly contribute to poorer education for residents through competition and "stealing" of procedures. However, I have seen no evidence of this presented, anecdotal or otherwise. A few attendings have posted on the threads the last few days that their residency had such programs, and none of them mentioned any issues with competition for procedures or any issues of poorer educational opportunities. If anyone has actual evidence to the contrary, I would be curious to see it. I would also love to hear more personal experiences from the physician perspective of those who have worked with PAs in these programs.
There are just over 300 total spots in PA residencies throughout the nation in any given year. This represents well under 1% the number of physician residents, and not all of these programs are co-located in hospitals with physician residencies. Therefore, the negative impact of these PA post-graduate training programs on resident training is over-exaggerated.
One thing about the recent outrage that I do understand and agree with is the pay discrepancy. I think PA residents should be paid at the same rate as physician residents. I also think that physician residents should be paid more for the hard work and long hours that they put in, regardless of whether there is PA post-grad training program at their hospital. I do know that many of these PA post-grad programs pay the same or less than physician residents though.
The last thing I wanted to address is the idea that PAs are trying to willfully mislead patients and steal unearned prestige. PA post-grad training is not some new, subversive ploy to misappropriate the "residency" terminology in order to blur the lines between PAs and physicians. As I showed above, the origin of these programs is almost as old as the profession itself. That they exist simply demonstrates the close history between the two professions; the PA profession was created by physicians too, after all, and this history is well documented.
This new outrage over these programs reminds me of another common "slam-dunk" that demonstrates the new, insidious degree of "midlevel encroachment": the wear of white coats by PAs. However, people must have missed the history lesson on that one too, because PAs have been wearing white coats since the very first class of PAs at Duke University in 1965. I don't particularly care for the white coat (and very rarely wear one), but just like PA residencies, white coats are not some new misappropriation that serves as a sign that PAs are trying blur the lines between the two professions.
PAs understand the significant training physicians have, and we do not claim equivalence of education or level of knowledge. The PA profession was designed to take on some of the duties physicians have, but PAs are not (nor do they claim to be) replacements for physicians; rather, they are skilled clinicians that complement the physician's role.
To close this novella, I have a great deal of respect for the knowledge base, depth of training, and experience of physicians. I don't agree with the push for independent practice of PAs or NPs either, but rather support the practice of PAs/NPs on physician-led teams. PAs receive solid training for what their role is designed for, but they shouldn't draw outrage for willingly taking a pay-cut (of 50% or more in some cases) to do additional advanced training to increase their competence and value to the team and to their patients.
Posted Feb 27, 2020, 4:07 AM UTC
When I walk around my hospital I don’t know if I’m looking at a doc, NP, PA, RN, Charge RN, Lab tech or what....Everyone has a long white coat (except the medical students). Patients will tell me their doctor was just in...sir that was your nurse. Anyway....
In my residency program we had issues with NPs getting procedures over Residents. It was so bad that several residents had to be placed on call list just to get the min needed to complete the program.
My program did this. They couldn’t put the NPs on call because they collectively refused. So the residents got shat on again.
NP’s have backing of nurses union, please keep that in mind. PA’s have no such backing which means, as stated by hypercidil above, PA’s tend to have the exact same hours and call as med students and residents. Also, on a little different note, it was and has been NP’s who push for independence. So much that PA’s, who had always, and still do, feel like physicians should lead team, are loosing jobs. If they don’t start getting more independence, they will be hurting as a profession in the future. Sadly, physician groups do their best to hold back the APP’s (PA’s) who have best education and training in the medical model, designed by physicians. PAs are trying to get optimal team practice in each state. That means physicians would not be required or responsible if they make a mistake. That means if a PA is sued a physician would not necessarily also be sued. That means the PA has freedom based on what the physician group or the hospital feels that they are able to do. But they will not be allowed to practice Independently.
Don't get me wrong, I do see an issue with this. My goal was simply to show that PAs wearing them is not some recent phenomenon indicative of a desire to "blur the lines", as is so often asserted, but rather began at the conception of the profession.
Like I mentioned, I don't care for the white coat personally, and am happy to just wear scrubs. I also think those large hang-tags for badges that outline an individual's role helps prevent confusion, and should be employed more widely.
Where I work nurses all wear a distinct color of scrubs, wear a name badge with the word "nurse" on it literally four times, and have a big bright blue "REGISTERED NURSE" badge underlaid behind our ID. When I walk into a room I say "hey I'm livinglavida, I'm a nurse here, etc."
I still get called a doctor nearly every day. Yes, I'm a dude. Sometimes I'll correct them and they'll continue to call me a doctor. There is no helping some people.
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Agree.
Sounds like an issue with your hospital then. Where I work, everyone wears different colored scrubs and everyone (yes, all nurses) introduce themselves and their role. I have NEVER seen a lab tech or a nurse wear a white lab coat.
What color do the MDs wear and what color does the NP wear?
Oh wait, let me guess they both wear the same color. Because if they don't it's inevitable that the NPs start complaining that they don't get to wear the black scrubs like the cool doctors do.
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No no. This is NPs getting the procedures over residents. The NPs are employed. Not students. They needed to be trained and were given priority over residents trainings.