Docs' Growing Concern at PAs Becoming 'Physician Associates'

Roxanne Nelson, RN, BSN

July 21, 2021

When the American Academy of Physician Assistants (AAPA) recently voted to change the name of their profession from "physician assistant" to "physician associate", there was a huge negative response from the physician community.

"AAPA's recent move to change the title 'physician assistant' to 'physician associate' will only serve to further confuse patients about who is providing their care, especially since AAPA sought a different title change in recent years, preferring to only use the term PA," said AMA President Susan Bailey, MD, in a statement

Confusion is only one of the issues that have some physicians irate. Another issue includes the suspicion that this could be a large step toward giving PAs greater ability to have independent practices. A third issue is that many suspect insurers want PAs to replace MDs for various aspects of patient care, as PAs are reimbursed at a lower rate. A name change that could lead patients to consider PAs as equal to physicians could help further that goal.

A recent Medscape poll found that most physicians who responded were opposed to the name change; 88% were opposed, with 72% stating they were "strongly opposed," and only 5% favored it.

Respondents also felt (87%) that "physician associate" implied a higher or lower level of education/expertise than PAs, and that it will lead to an increase in negative interactions (68%) between physicians and PAs.

More than half of nurses/nurse practitioners (59%) who responded were also opposed to the name change.

Easier for PAs to Move Toward Independent Practice?

One of the concerns medical groups raised is that the name change is part of a move to independent practice. The terms "dependent" and "interdependent" have long been used to describe the physician/PA relationship since the early days of the profession, and most state laws are very prescriptive as to how this relationship is defined.  

"We have worked with PAs throughout my career, and this issue is more complex than what is on the surface and tends to be a bit more nuanced," said Joseph Twanmoh, MD, an emergency room physician and president and founder of Queue Management. "They fill a huge need as there are not enough physicians. Because of distribution issues there has always been a shortage in primary care," he said.

Twanmoh explained that in emergency medicine, it was felt that PAs could care for lower acuity patients. "There were economic incentives to do that," said Twanmoh.

Over the years PAs have been given more and more responsibility. Twanmoh feels that the attitude may be that because they are doing so much, they should be independent practitioners. "And that's the difference between PAs and nurse practitioners," he emphasized. "State statutes allow nurse practitioners to be independent providers and they are licensed by the board of nursing."

PAs, however, are licensed by medical boards and work under the physician license. "Depending on the situation, they can get very good or very light supervision," he said. "Supervision can be variable depending on the situation, and some PAs are put into situations they shouldn't be in. I have been in situations where the staffing was such that I could not adequately supervise them."

Independence then leads to the idea of separate practices without a physician, so that would do away with physician oversight. "I think that's a problem and the way they are being used now is also a problem," said Twanmoh. "But I do feel that the name change comes with the goal of moving toward independent practice."

Money Is Also a Factor

Twanmoh also believes that factors beyond the PA association are driving the move towards a name change. "I suspect there are corporate issues at play as well," he said. "In emergency medicine, for example, many health systems have been moving to reduce physician hours and replace them with PAs."

This can create problems because the acuity mix has shifted significantly over the last 10 years. "We don't have a lot of low-acuity patients anymore," Twanmoh pointed out. "And in the post-COVID era it has shifted even more. We have more moderately complex and high complex patients."

Thus, money becomes a driver. "Sixty percent of healthcare costs are related to labor and the entity responsible for finances wants to keep the costs down," he said. "So that's the other motivation for this."

Kevin Klauer, DO, chief executive officer of the American Osteopathic Association (AOA), agreed that cost could be involved. "Some physicians have been concerned about the substitution of physician-level care with nonphysicians, although to what degree this is happening and for what motivations, I can't speak to that," he said. "But there are many physicians who believe that their practice and/or and their employment status may be at risk."

He noted that many healthcare institutions are looking to have the most cost-effective way to deliver care. "The desire for cost-effective care could be leading to some skill set substitutions," said Klauer.

"When physicians refer to an MD/DO partner in their practice or a colleague on their medical staff, they commonly refer to that individual as their associate," explained William T. Thorwarth Jr, MD, chief executive officer of the American College of Radiology (ACR). "This name change will imply to the patients and others that this 'physician assistant' has the training, education, and experience of having received an MD/DO degree."

Bailey noted that the move is "clearly an attempt to advance their pursuit toward independent practice."

The AOA also sees the name change as part of a push towards increased autonomy that began several years ago. The AOA notes that this move to more autonomy began with the "optimal team practice model adopted in 2017 and advocates for the total elimination of any legal or regulatory requirements that PAs must maintain a relationship with a physician, and now through their recent vote to change the PA name to physician associate."

The ACR, which also announced opposition to the name change, stated that the PA title accurately reflects the training of these professionals and their role in any physician-led team, and any change would lead to confusion among patients as they make important healthcare choices. The ACR actively opposes supervision or interpretation of radiological exams or procedures by nonphysician providers.

Thorwarth told Medscape that there is a vast difference between MD/DO education/training and experience and that required for achieving a PA degree/certification. "They should not be portrayed as bringing the same qualifications to the patient," said Thorwarth. "Applying the name 'physician associate' implies equivalent credentials."

And in their statement, the American College of Emergency Physicians/Emergency Medicine Residents' Association also voiced their opposition, reiterating that the term "associate" creates confusion and "does not appropriately convey to our patients or the public the role physician assistants serve while working under emergency physician-led care."

Still, the name change itself may be most problematic. "The word associate implies being an equal partner, and it carries an important message and who are we giving that message to?" Thorwarth questioned. "Most likely the patients. It can be confusing, and patients shouldn't have to try to figure out the credentials of the person caring for them."

However, the name change isn't going to happen overnight, and for now, the title of physician assistant will continue. Current guidance from the AAPA is not to start using the term "associate" until regulatory and legal hurdles are cleared, explained Randy Danielson, PhD, PA-C Emeritus, DFAAPA.

"The title change was step one of about 350 steps that will take place over the next 3-5 years," he said. "We will have to see federal changes in statutes/policies and most critical will be going to each state to change all statutes that pertain to PAs."

PAs Feel the Change Is Positive and Necessary

The decision to change the name was several years in the making. In fact, according to Danielson, who is professor & director, doctor of medical science program, Arizona School of Health Sciences, Mesa, it actually began decades ago. "Forty-seven years ago when I graduated, I was a MEDEX," he said. "Then a few years later, the profession consolidated the terms 'MEDEX', 'child health associate', 'physician assistant', and 'physician associate'."

The PA profession was created to fill a unique role as "assistants" or "extenders" to primary care physicians. This was in response to a shortage that was acknowledged in the mid-1960s. The first class of PAs was initiated in 1965, with four Navy Hospital Corpsmen who had received considerable medical training during their time in the Navy. Eugene A. Stead Jr, MD, of Duke University Medical Center, and who put together the first PA program and based the curriculum on his knowledge of the fast-track training used for physicians during World War 2. The first PAs graduated from Duke University in 1967.

Over the years, however, core knowledge that was required and the scope of practice increased, thus "outliving the name of assistant," said Danielson. "In 2018 the AAPA House of Delegates spoke clearly about a name change and the board hired WPP, a national marketing firm, to study the name change."

Surveys were sent to PAs, physicians, the public, and administrators/regulators, and showed that 90% of PAs felt their title was not representative of their role. "The goal of WPP was to find a meaningful title," he explained. "The House overwhelmingly chose physician associate."

Danielson believes that the PA profession can professionally separate from physicians and still collaborate clinically. "The backlash came quickly with worries about patient safety and patient misunderstanding of the new name," he said. "Anecdotally, many physician colleagues are saying that they think this is a good idea and are surprised that we haven't done it sooner."

Physicians and PAs React

Many Medscape readers commented on the poll, and not surprisingly, PAs generally supported the name change while physicians did not.

One PA commented that he wasn't sure how changing from "assistant" (when there is no assisting) to "associate" (when there is associating) is confusing. "Does the confusion come from continuing paternalism of physicians who think they know more than patients?"

In response to his comment, an ER physician wrote that "you may call me paternalistic, but I believe most readers would agree that physicians know more about bodies and medicine than patients. Otherwise, we wasted many long years in educating ourselves for that purpose."

Some physicians also agreed that the use of the word "associate" will be confusing. One noted that she can understand wanting to change the name, "but associate is very confusing to patients when already everything is confusing to patients. None of my patients ever realize they are not seeing physician as it is. I call a physician I refer to or work with an associate."

Another physician agreed. "At my large multispecialty group practice, before we made partner, we were called 'associate physicians'. How is PAs calling themselves "physician associates" NOT confusing, or conflating the two?!"

However, a dentist questioned the use of the term associate for an entirely different reason. "The word 'associate' first came into general use by Walmart and Amazon for its employees. Now many retail stores use this term for employees. I do not think it raises the status of PAs and will likely have the opposite effect. Associate now carries an unspoken image of someone selling something." 

One physician did agree with the name change, saying that it seemed reasonable and that informed patients will use the internet to determine what credentials mean. "Some patients don't bother to discern whether the clinician they see is a CNS, ANP, PA, MD, or PhD.  As long as a nonphysician does not represent themselves as a physician, I agree with the change."

However, another physician thought that a better option would be for PAs to select a name without the word physician in it. And several others agreed, including PAs.

"A lot of us would rather have the new title of medical care practitioner because that's precisely what we do, but can you imagine the uproar such an attempt would create?" one PA wrote.

Another PA pointed out that medical care practitioner had been the alternative choice. "Sadly, physician associate was chosen. Still beats assistant — my patients thinking I'm a medical assistant is more endangering and confusing."

A physician responded that he was "exactly right. A PA is not a physician, and is certainly not an associate of a physician by today's understanding. However, a PA is also not an assistant, other than 'assisting' in getting more straightforward cases seen sooner and for less cost."

She noted that associate "is misleading at best and deceiving at worst. Paramedics don't call themselves 'ambulance physicians' or 'paraphysicians'."

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