To view this article in PDF form, click here. To view this article in PDF form, click here.
To the Editor:
In the December 2007 JAAPA Editorial, "Achieving mastery through the competencies,” Patricia Guerra, chair of the AAPA Education Council, begins a re-evaluation of the competencies for the PA profession that were set by AAPA, ARC-PA, NCCPA and PAEA. This group agreed these competencies included medical knowledge, interpersonal and communication skills, patient care, professionalism, practice-based learning and improvement, and systems-based practice. The editorial also spoke of peer and patient review of physician performance.
The American Board of Internal Medicine (ABIM) working with the American College of Physicians (ACP) has realized the difficulty in evaluating professional competency only through a test. They recommended a new way of evaluating the above competencies that involves peer, patient, and practice systems. This involves data related to the medical practice, a plan for practice improvement, testing of medical knowledge, chart reviews, interpersonal skills, and CME.1
Competency and recertification cycles are related. The 2007 AAPA House of Delegates was presented with a resolution to extend the PA recertification cycle to 10 years from 6 years. The resolution was rejected by the reference committee because of conflicts with AAPA policy. The resolution will be reintroduced at the annual conference in San Antonio, Texas, (May 24-29, 2008) with special attention to those conflicts.
Throughout the past year the PA literature has responded to this resolution with numerous letters of support for a 10-year recertification cycle, the same as the overwhelming majority of our fellow physician groups.2
The American Academy of Family Practice is extending its recertification cycle to 10 years from 7 years, starting in 2010;3 and the American Society of Internal Medicine has a 10-year cycle.4 I request that the AAPA Education Council evaluate the ABIM/ACP method and report on it to the HOD.
Ironically, Ms. Guerra mentions Dr. William Osler, the noted author and educator. Concerning testing he said, "Perfect happiness for student and teacher will come with the abolition of examinations, which are stumbling blocks and rocks of offense in the pathway of the true student.”5
Bernard Stuetz, PA-C, MA
REFERENCES
1. About maintenance of certification: the current process and its evolution. American College of Physicians Web site. http://www.acponline.org/moc/about.htm. Accessed January 15, 2008.
2. Stuetz BJ. A plan to revise PA recertification. ADVANCE for Physician Assistants. 2006;14(11):21. Comments. ADVANCE for Physician Assistants Web site. http://physician-assistant.advanceweb.com/editorial/content/editorial.aspx?CC=92670. Accessed January 15, 2008.
3. How the ten-year option works. American Board of Family Medicine Web site. http://mcfp.theabfm.org/chartF.aspx. Accessed January 15, 2008.
4. ABMS maintenance of certification. American Board of Medical Specialties Web site. http://www.abms.org/Maintenance_of_Certification/ABMS_MOC.aspx. Accessed January 15, 2008.
5. Osler W. Medical education. In: Silverman ME, Murray TJ, Bryan CS, eds. The Quotable Osler. Philadelphia, PA: American College of Physicians; 2003:171-225.
To the editor:
Regarding "Doctor and patient: A matter of degree” [Sounding Board, January 2008, page 71], one may laugh at the article written, but the subject is fraught with real problems.
I have seen an NP with her doctorate insist on being addressed as "doctor” and introduce herself as "doctor” to her patients, leading to patient confusion and physician ire to the extent that she was let go from her position.
In another instance, a PA with two doctorates, an excellent clinician who never tooted his own horn, was brought to task because his personal license plate on his vehicle, "dr wes,” was noticed by or brought to the attention of the physician staff at our facility. The PA was called into the administration and discussions were held regarding the appropriateness of his license plate. Only the ruling of the state department of motor vehicles swayed the administrative staff from action against this PA.
Physician and health care provider egos are the principal source of this problem.
I have found that our patients cannot tell the difference between a PA, NP, or MD, despite our verbal introduction or the fine print embroidered on our lab coats and picture identification badges as to our level of education or provider position. Anyone in a white coat who will provide competent care and the services desired by the patient (whether it be an unnecessary antibiotic, ancillary test, or the latest direct-to-consumer medication) in the time convenient for the patient is acceptable to the general public.
I caution all who find it necessary to advertise their level of education or who find the pursuit of knowledge to be a contest to leave their egos at home and strive to provide the best medical care possible to the patient, as was the original intent of the health care profession.
Thomas R. Butler, PA-C
Fort Bragg, North Carolina
To the editor:
I recently read the article "Doctor and patient: A matter of degree” in the January 2008 issue. I must say, this new doctoral degree for PAs certainly muddies the waters even further. I agree with the trend of the profession, that of offering a master’s level degree upon completion of training and graduation. As this becomes more commonplace in the future, the doctoral degree is a natural and appropriate aspiration for those wishing to further their academic studies or even participate in, or carry out, research to a greater degree (no pun intended). So what do those individuals call themselves?
At every university or 4-year college in the nation, instructors who have earned the highest degree in their chosen field are given the title of doctor. Those with a master’s degree are not called doctor assistants. Instead, they usually go by "professor.” Are the doctors in the university setting professors? Certainly, but we call them "doctor” out of respect and recognition for the years of study and level of training they have satisfied. Others who perform the teaching role in those institutions of higher learning are often called professor.
In the field of medicine, we PAs find ourselves in a similar situation. We (collectively) are not doctors (though some have obtained a doctoral academic degree). We should not aspire to have our patients or colleagues call us "doctor,” for we have not satisfied the years of formal training and study, nor have we been trained in an MD or DO program. But the name "assistant” is entirely inappropriate.
Why not follow the tradition of our academic counterparts? All those who teach are commonly referred to as professors, while those who additionally hold a doctoral degree can use the term doctor. In many dictionaries (including medical dictionaries), I have found the definition of physician to mean any person formally trained in the practice of medicine. By this, then, are PAs not physicians? I believe so. HOWEVER, we are not doctors. Would it be so awful if we aspired to be called physicians, letting our counterparts with the additional level of training and education retain the title of doctor?
While I, myself, continue to correct my patients who call me doctor (some even insist on it after I have fully explained the matter) and ask that they call me by my name or refer to my position as physician assistant or PA, I would very much like to see our profession more clearly defined in its title.
A physician practices medicine.
A doctor practices medicine but has earned the right to use a different title by means of additional study beyond that which other physicians have accomplished.
Eric B. Lowe, PA-C
Richland, Washington
Author’s response:
I am tickled pink that Mr. Butler and Mr. Lowe took the time to compose their thoughts in response to my recent Sounding Board article. As physician assistants, we are defined by (1) the legal nomenclature of our profession, and (2) the scope of our practice. Few would argue with the second point—we practice medicine—here I include surgery as well—under the auspices of our supervising physicians within the limitations of the scope of our practice. In so doing, we "strive to provide the best medical care possible to the patient,” as Mr. Butler so aptly puts it.
Legal nomenclature governs our practice as outlined by the various state physician assistant practice acts and statutes. We are granted the legal authority to practice medicine as (and only as) "physician assistants.”
Degrees define our level of education, not our clinical practice. Many of the first PAs did not posses undergraduate degrees, yet they delivered quality medical care as PAs. In today’s medical marketplace, nearly all PAs possess an undergraduate degree; and many programs now confer master’s degrees on new graduates. Although a small number of PAs have elected to pursue doctorates, in the United States only physicians (graduates of schools of medicine) are awarded the Doctor of Medicine (MD or DO) degree.
As practicing PAs, it is imperative that we do not misrepresent ourselves to the public. Cultural norms dictate that we refrain from referring to ourselves as doctors or physicians. That being said, as Mr. Lowe infers, there will always be those patients who either do not understand the definition of the profession or choose to ignore it.
"What’s in a name?” the Bard muses. I find it amusing that in the British medical system, general practitioners, who possess a Bachelor of Medicine degree, are referred to as "Doctor” (abbreviated "Dr” without the terminal period), whereas surgeons enjoy the more formal title of "Mister” (abbreviated "Mr” without the full stop). For some additional educational fun, readers may wish to consult a small treatise at M Lynne Murphy’s blog on the subject of physician titles (http://separatedbyacommonlanguage.blogspot.com/2007/12/physicians-titles.html.)
Brian T. Maurer, PA-C
Enfield, Connecticut