The role of mid-level practitioner is one of the fastest growing and most important in American Medicine today. In particular, more and more physicians, medical practices, and medical care systems are looking to physician assistants (PAs) to improve the efficiency, effectiveness and reach of patient care. Furthermore, the projected shortage of physicians, particularly in the primary care specialties, has placed PAs in increasing demand, with salaries to match.
The 2017 median annual income for physician assistants is calculated as almost $105,000 by the Bureau of Labor Statistics. The Bureau of Labor Statistics also estimates that employment of physician assistants will grow 37 percent between 2016 and 2027, outstripping all but four other occupations (solar photovoltaic installers, wind turbine service technicians, home health aides and personal care aides).
According to an article in the journal Public Health Reports (2011 Sept-Oct, 126(5): 708-716), during the 15 years 2010-2025, the number of clinically active PAs will increase by almost 72%. In response, more and more young people are considering careers as physician assistants and those already part of the profession are seeking the best and most satisfying positions in what is currently a strong “buyer’s market”.
Physician assistants occupy a unique niche within the health care delivery system. While provided varying, but generally significant autonomy in the practice of medicine, the physician assistant’s clinical activities are structurally and legally linked to a physician’s medical practice. In many states, and within many hospital medical staffs, physician assistants’ licensing and medical staff membership respectively are actually tied to a specific, named physician. Regardless of whether the supervisory relationship is legally defined or not, functionally, this results in a very intimate professional working relationship between the PA and the supervising physician. This relationship carries with it a set of behavioral and professional expectations on the part of that physician that may or may not be overtly articulated. It is therefore important for the physician assistant, or aspiring physician assistant, to develop genuine self-awareness and to understand the implicit and explicit attributes expected and desired by the typical supervising physician. Only by doing so 1) can the aspiring PA determine whether the PA profession is the right one for him/her and 2) can current PAs assure their own success and happiness by working to develop and exhibit those professional characteristics considered most desirable by physicians. Following is a list, in no special order, of the seventeen most important attributes desired by physicians engaged professionally with a PA:
Kindness, Affability and Empathy
The PA is an extension of the physician him/herself and most physicians aspire to be viewed by their patients as kind, caring, and considerate. The degree of patient satisfaction is even being used in some health care systems to determine, in part, physician remuneration. As an extension of the supervising physician, the PA is viewed by the patient as one with the physician and must reflect the physician’s professional and caring attitude towards all patients. The patient responds to the physician and PA as a unit and both are responsible for a positive and constructive doctor-patient relationship. It only requires a small misstep by the PA to poison that relationship permanently, for everyone. And, a poisoned patient relationship is a lost patient to the practice.
Nobody wants to work with a “Debbie Downer”. Persistent negativity, complaining, apathy and pessimism create an unpleasant and depressing work environment that can be passed on to other office and hospital staff and even on to patients. Choosing to be a PA is a very positive choice and one should also choose an employed PA position in which one can be optimistic and enthusiastic. Optimism, like pessimism, is infectious and helps assure that the PA is and remains a welcome and valued member of the patient care team. PA enthusiasm also demonstrates the PA’s approval of the physician’s practice and such implicit flattery can only be greatly appreciated by the doctor.
The importance of clinical competence almost need not be stated. A supervising physician will allocate autonomous practice to a PA to a degree directly proportional to his/her clinical competence. The broader range of responsibility that a physician can delegate to a PA, the less that physician has to accomplish personally and resultantly, the happier he/she is. Furthermore, a PA’s clinical competence assures the physician (and the patient) of accurate communications and good judgment. This results in enhanced patient confidence in the PA-physician team, improved patient satisfaction, and overall better patient care.
Patient care is an intense, busy, and sometimes chaotic enterprise. An outstanding PA needs to keep up with the pace of a physician and with his/her physician’s practice. While this does not mean rushing patients and making them feel pressured, it does mean taking a targeted, appropriate history, doing just the right, appropriate, and targeted physical, making clinical decisions crisply, and communicating your findings efficiently and effectively to the patient (and/or the supervising physician as appropriate). Long rambling histories, clumsy, redundant exams, and poorly constructed, windy discussions with the patient will prolong encounters and result in poor patient flow and productivity. Physician assistants are generally hired to improve physician and office productivity, not degrade it.
Intellectual Curiosity and Passion
PAs take positions in a wide variety of clinical settings, in many of which they initially have had little or no previous formal training. In order to ultimately excel in these clinical settings, the PA must be ferociously committed to “learning on the job” as well as extending such an effort to the home, continuing their specialized education independently and on their own time. The PA should be motivated and excited about acquiring this new expertise, recognizing that the greater and deeper their expertise, the more valuable they are to their supervising physicians… and their patients. The PA must also be a life long learner, keeping up with medical advances and therapeutic changes in his/her area of clinical practice. Narrow specialization, with a deep band of expertise spanning the common components of the specialty, is the “sweet spot” of practice for the PA. A knowledgeable PA should have more practical knowledge in his/her specialty than the average physician who is not trained in that specialty. This creates enormous value for the supervising physician and permits the PA to function truly as a clinical extender for that physician.
Above Average Intelligence
In order to achieve a high level of competence and expertise in their chosen area of clinical practice, the successful PA must be intelligent. The PA must have good learning skills, enjoy reading and acquiring new knowledge, and be able to synthesize information across a variety of disciplines. Comfort with language, chemistry, biology, physiology, mathematics and the social sciences is essential to build and maintain the knowledge base required for successful clinical practice. However, genius or academic brilliance is not required for success. Those academic elements required for successful clinical practice are emphasized and reinforced daily through clinical practice, making learning easy. Thus, above average intellectual ability coupled with intense commitment (see below) is what is required for success. That which the PA can control, i.e. effort, is a much larger determinant of ultimate clinical excellence than innate intellectual ability.
Drive and Commitment
Physicians tend to be hardworking, intelligent, driven, and competitive people who are used to being successful. The supervising physician will expect a comparable level of drive and commitment from the PA with whom he/she chooses to practice. The PA, like the physician, should hold him/herself accountable to achieving a level of professional performance that is no less than his/her absolute best. The PA should be intensely committed to excellence in patient care and to the development and maintenance of a successful clinical practice. It should be the PA’s practice as much as that of the physician. The PA should incorporate and reflect the work ethic and values of the supervising physician and embrace the clinical practice and its goals as his/her own.
In order to practice with significant autonomy as a physician assistant, the PA must be completely confident that he/she possesses the necessary clinical knowledge and skills to make important decisions for patients in lieu of the supervising physician. He/she also must be willing and able to exercise those skills on behalf of the patient. The PA cannot be routinely disabled by doubt and indecision. However, self-confidence must be born out of true competence, not bravado. Supervising physicians are not seeking to work with PAs who want the physician to reconfirm all physical findings and double-check every decision with them. They are looking for a true partner who can confidently and reliably handle most of the regular and more routine aspects of their clinical practice. This frees the physician up to focus on more complex tasks and clinical decisions that only the physician can make. A confident PA also reassures his/her patients that they are in good hands and are receiving competent care.
As important as it is for the successful PA to be self-confident, it is probably more important that he/she also be humble. A PA must clearly identify and adhere to their limits of knowledge and expertise. Knowing when to call in the supervising physician and/or to seek outside help is essential. No clinical practitioner, PA nor physician, can possibly be expert in everything, even within his/her own practice specialty. Patients’ lives and well-being are at stake. The quality practitioner must be able to admit, “I don’t know” and get help.
The practice of medicine is one of the world’s oldest professions. Physicians take pride in being part of a community that is based upon knowledge and lifelong learning, and is solely committed to the betterment of one’s fellow man. Patients place inordinate trust in their physicians and care providers, telling them things they have told no other human being; allowing them to touch, prod and even cut areas of their body accessible to no one else. Patients do this with the belief and expectation that their physician/provider is always acting in their best interest. PAs are now full members of this unique and privileged provider community. They must embrace the values of professionalism just as intensely as physicians. They must conduct themselves in a manner that always places the patient first. This includes hygiene, manner of speech, dress and attitude. Patients want professional caregivers and physician supervisors want to work with highly professional PAs.
Loyalty may seem like a rather strange trait to expect of a PA. However, it may be more evident if one considers the physician-PA relationship to be a true partnership (as opposed to a competition). In addition to projecting competence and professionalism him/herself, the desirable PA will also “manage up” the supervising physician to his/her patients. What this means is that the PA should always work to make the patient comfortable with the care that the supervising physician is providing. The PA should feel free to (honestly) attest to the supervising physician’s skill and competence, using anecdotes as necessary. By helping to engender confidence by patients in their physician, the PA is enhancing the confidence of those patients in their entire care team. If a PA does not feel comfortable with their supervising physician and/r the care provided, he or she should seek an alternative position. PAs should never “bad mouth” the physicians with whom they work nor should they second guess or question decisions by the physician in front of the patient. Remember, this is a partnership, and if the patient loses confidence, the whole care team suffers.
The practice of medicine is not often about brilliance, it is more often about details. Most medical care decisions are not difficult, but, they do depend upon details, i.e. detailed clinical information,… copious amounts of it. A large number of medical malpractice cases arise from the lack of attention to detail. Failure to respond to an abnormal lab test or follow-up on an ambiguous x-ray finding are typical examples of inadvertent but nevertheless significant medical negligence. Given how much information passes by the clinician each day, meticulous and compulsive attention to detail is required of all those involved in a patient’s care, including the PA. A meticulous and compulsive attention to the details of patient care will be greatly valued by the supervising physician. Such attention is a requisite of excellent patient care… and may keep both the PA and physician out of the courtroom.
Honesty should be a cornerstone of clinical behavior but it is surprising how often and how easy it is to neglect. Electronic medical records, medical payment structures, and repetitive clinical routines conspire to subtly encourage the clinician to document historical elements and exam findings that may or may not have been genuinely acquired. Everyday medical communications among practitioners may lead to dishonest statements (“white lies”) promulgated by one to avoid embarrassment. For example, It is easier to say that the lung sounds were clear than to admit that you forgot to examine the lungs entirely in a febrile patient. Yet, such oversights and errors occur regularly. The excellent PA is meticulously honest, reporting only exactly that which he/she heard, saw, and felt. Mistakes and oversights are a common and universal characteristic of any human endeavor. Redundancy, as embodied by the PA-physician team is a powerful tool to reduce such errors. However, errors can only be identified and addressed in a completely open and honest environment where the honesty and the patient are placed first, far above the necessity to save face or avoid embarrassment.
Health care is a 24/7 activity with unpredictable peaks and valleys. Emergencies must be addressed, regardless of the day of the week or the time of day. Physicians are known and expected to work long hours and to be available on short notice while “on call”. Although the life of a PA is more organized and predictable, and his/her work schedule more determinant, the desirable and successful PA will be sensitive to these unpredictable demands their supervising physician’s time, and work within reason to mitigate them. This may mean staying later on a Friday afternoon to help the supervising physician deal with an emergency or coming in early to help with an unexpected surgical procedure. By not slavishly adhering to a time schedule and exhibiting concern and some time flexibility, the PA will provide a valuable and much appreciated service to the physician.
The skill of speaking clearly, concisely, and accurately is underappreciated but will greatly serve the aspiring PA. So much of medical care involves accurate communication. Medical students are drilled in the skill of complete and concise “patient presentations” throughout their training. This skill is no less valuable to the PA. Conveying relevant, concise, accurate, and complete information to your colleagues and/or your clinical supervisor is essential for excellent and efficient patient care, as well as to prevent medical error. The complementary skill of communicating empathetically yet accurately and completely with your patients is equally valuable. Don’t overlook this skill in your clinical training and be prepared to model your communications behaviors after the skillful colleagues and mentors who surround you. There is also a growing curriculum of written information that addresses patient and inter-provider communications. Take advantage of it.
Technical skill is required to some degree by almost all clinicians but is a significant requirement for those engaged in procedural specialties. PAs must honestly assess 1) whether they are truly interested in a technically oriented career and 2) whether they have the requisite dexterity to excel at technical tasks. Surgical PAs often accompany their supervising physicians into the OR and scrub at their sides. They participate actively in surgical procedures and may be left along to “close up” after the complex surgery is competed. While glamorous for some, this life may be tedious for others. A successful PA in a procedurally oriented specialty must have the motivation, the temperament and the specific technical aptitude to be successful. It is analogous to sports; if you can’t throw a baseball, don’t aspire to be a pitcher. Conversely, if you do have such inclinations as well as the required technical aptitude, you should excel in your chosen interventional specialty and be able to add unique value to your physician’s practice.
As noted above, during PA school, the typical PA acquires a very broad base of practical clinical information in a very short time. There is no required residency or fellowship training as there is for physicians. Yet, physician practices and health care systems appreciate and often seek some degree of specific specialty clinical experience among the PAs they employ. If you, as a PA in training, have a specific clinical interest, you should take every opportunity to volunteer and take electives focused on that specific area of interest. Obtain as much practical clinical training in your specialty area as you can. If you are interested in emergency medicine, train and work as an EMT; volunteer to work in an emergency department. It is true that much additional specialty training can and will be acquired after graduation and “on the job”, but those who have preceding experience have a leg up on the competition for the best positions. During the past decade or two, a large number of specialty oriented PA residencies and fellowships have been developed (PA residencies and fellowship programs) which are accessed through competitive admissions processes. A PA should seriously consider enrolling in one of these programs after graduation or early on in his/her career. Most programs are 12 months in length and after completion, the PA will find that he/she is in a much better competitive position for their ideal position
Eric M. Mazur, MD MACP
Dr. Eric Mazur is a seasoned physician executive with a 30+ year career as a clinician, research scientist, medical educator, health care executive, and physician leader. Dr. Mazur served as Chairman of Internal Medicine and then Vice President and Chief Medical Officer at Norwalk Hospital in CT.