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Physician assistants share with physicians and others the broad title of doctor in that their clinical role encompasses providing generalist care to patients. PAs have assumed the ancient role of healer and now have logged a 40-year history as a mainstay of primary care delivery.
This role has been called "big doctoring" by Fitzhugh Mullan, a physician who uses this term to mean "[W]hat the generalist does: doctoring that embraces the whole person, that values comprehensiveness and continuity, that welcomes the richness and the complexity of the complete human being."1 In short, Mullan is talking about being a primary care provider. In the highly specialized world of modern medicine, is that still what PAs do?
The Way We Were...
Mullan's book Big Doctoring in America is a wonderful tribute to a generation of primary health care providers-allopathic and osteopathic primary care physicians, nurse practitioners and PAs?who sought careers in big doctoring. This rich oral history captures the stories of people who came of age in medicine in the 1970s and 1980s in pursuit of the Holy Grail of big doctoring-that is, becoming a real primary care doctor. Their stories reveal the changes in medicine and society that affected their pursuit and how the notion of big doctoring evolved for them.
In many cases, the stories in the book reveal the difficulties of practicing big doctoring and the marginalization of primary care and primary care providers in the health sector. Bear in mind that this was occurring during a time when specialization and subspecialization accelerated toward dominance in American medicine.
There were and still are many PAs who were part of this generation of providers who aspired to big doctoring. Many of these PAs were ex-military corpsmen who embraced the role of the PA as a primary care provider. After all, this was the social mandate for the profession, one encouraged by organized medicine and funded by the federal government. PAs were seen as the answer to the demise of the old American GP. With physicians increasingly leaning toward the specialties, PAs were the answer to providing primary care. But this might become the lost generation of PAs.
...And the Way We Are
It seems clear that fewer PAs are seeking to do big doctoring. According to the 2007 AAPA Physician Assistant Census, released in October, only 34.2% of practicing PAs now are in the primary care disciplines of family medicine, general internal medicine or general pediatrics.2 Sadly, the percentage of PAs in family medicine has sunk to an all-time low of 24.9%. At one point, more than half of the profession practiced in family medicine.
The reasons for PAs' trend away from primary care are familiar. Among physicians, primary care is a discipline that has no respect. The "real doctors" seek to be high-powered specialists. For PAs choosing specialties and subspecialties, jobs are far more plentiful, salaries are higher, educational debt can be erased sooner and work hours and lifestyles can be more easily managed. Ironically, the primary care PA of today is going in the same direction as the old GP of the 1960s.
What will happen to the role of the PA in primary care? Can America continue to count on PAs to be generalists? With more than 65% of the profession now practicing in specialties and subspecialties, it is legitimate to ask whether PAs still can lay claim to the role of big doctoring.
Will We Still Need PAs?
Another somewhat discouraging look at modern doctoring sees a deeper, more disturbing transformation of the role of the physician as healer. John D. Lantos, a pediatrician, observes a diminution of the role of the physician from one that is the traditional general doctor who has been supreme in the matters of health and medicine to one that is more narrow, technical and litigious, and one that is shared with many others.3
Lantos' provocatively titled book-Do We Still Need Doctors?-reexamines the role of the physician in modern society given the emergence of other health care providers. Lantos raises a number of profound questions about the roles of health care professionals of all types.
Lantos notes that the world has assaulted the traditional role of the doctor and as a consequence has made it more difficult for physicians to do big doctoring. Lantos wonders whether society should entrust physicians with the powers given to them by states and whether doctors are still the best professionals to make judgments on patient problems that extend beyond medical boundaries and far into the socioeconomic, psychosocial and political realms.
The roles of physicians and PAs have evolved and continue to evolve in our complex health care system. Unfortunately, the primary care role seems to be fading. Medical groups remain concerned and have labeled the current circumstances in primary care as a crisis.4 In this situation, it appears that PAs are more a part of the problem than of the solution. Will PAs remain as providers who aspire to do big doctoring? It will be a stern professional challenge for PAs to remain primary care providers in a specialized world.
James F. Cawley is professor and interim director of the PA program at the School of Medicine and Health Sciences at The George Washington University in Washington.
References
1. Mullan F. Big Doctoring in America. Berkeley, Calif: University of California Press; 2002.
2. American Academy of Physician Assistants. 2007 AAPA Physician Assistant Census Report. Available at: http://www.aapa.org/research/07census-intro.html. Accessed November 8, 2007.
3. Lantos JD. Do We Still Need Doctors? New York, NY: Routledge; 1997.
4. Kirk LM. Who will take care of you and me? Facing the crisis in primary care. ACP Observer. 2006 Jul-Aug. Available at: http://www.acponline.org/journals/news/july06/president.htm. Accessed November 8, 2007.
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