I was discouraged to hear a physician suggesting that we use physician assistants (PAs) to function like cardiologists and intervenionalists. ("One solution to physician recruiting problems: physician assistants," February ACP-ASIM Observer.)
If we truly are concerned about attracting more students to primary care careers—as is mentioned in the same issue ("Letters")—I don't think advocating a greater scope of practice for PAs helps the cause.
As an internal medicine resident, I'm regularly in contact with third- and fourth-year medical students who are trying to choose the area they will train in after finishing medical school. One of their most common concerns about going into general internal medicine or family practice is the expanding practice rights of PAs.
They wonder why they should have to go through four rigorous years of medical school, followed by three or more years in residency—and pay more than $125,000 in tuition—only to complete training and find PAs doing nearly the same job that they do.
I have personally worked alongside PAs and trained several PA students. Their level of knowledge and comprehension of medicine and pathophysiology comes nowhere near a third-year medical student's in most cases. Sure, they can follow "cookbook" medicine, but that does not equal excellent care.
To further complicate this dilemma, many patients aren't even aware that their caregiver is not a physician. All too often, I have seen patients call PAs "doctor," and the PAs do nothing to correct them.
I believe the title "doctor" has to be earned. Certainly a bachelor's degree and two years of training does not give a PA the right to that title.
Ironically, we physicians are partially to blame for this problem. Under the strain of falling reimbursements and the pressure to see more patients, we have resorted to hiring these so-called "mid-level providers." At some point, however, we must clearly draw the line between physician and assistant before it becomes permanently blurred.
Dominic J. Valentino III, ACP Associate
Political incorrectness notwithstanding, I strongly disagree with the ACP position paper calling on doctors to educate themselves about the cultural practices of various immigrant groups to accommodate potential drug interactions with "traditional medicine." ("ACP outlines plan to reduce racial health care disparities," May ACP Observer)
This position struck me as social pandering rather than sound clinical advice. It absolves patients of responsibility for understanding the allopathic medicine contract they enter when they seek modern medical help. It also unduly burdens physicians with the responsibility for negative outcomes that stem from a patient's use of potentially harmful traditional medicines.
The position endorses a medical relativism that says what an allopathic physician prescribes is potentially dangerous, but what a patient opts to take is inherently valid.
Patients'—and doctors'—perception of medical care should not be relative. We require all parents, for example, to learn about their children's allergic reactions and avoid giving children trigger foods or medicines. Should we not expect similar medically responsible behavior from "cross-cultural" adult patients?
When an immigrant buys a car, is he or she exempt from obtaining a license and insurance, obeying the seat belt law or driving on the right, lest these practices offend his or her traditional cultural practices? Is this reasonable or even desirable?
Instead of proposing separate clinical standards for immigrant (or poor or minority) patients, we should exhort patients to educate themselves about the side effects and interactions of traditional medicines, and to try to avoid traditional medicines when they interfere with needed allopathic therapy.
Adapting to the realities of a plural society is a laudable goal for physicians as a group. But making it a standard of care for American internists to meet every cultural contingency with an alternate clinical approach is unwise, unfair and ultimately a disservice to patients.
Day F. Hills, ACP Member
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