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.
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