Liam James Doyle for KHN
After 23 years as a physician assistant, Leslie Clayton remains haunted by one facet of her calling: her title. More precisely, the word “assistant”.
Patients asked if she was heading to medical school or in the middle of it. The term confused even her family, she says: It took years for her parents to realize that she was doing more than taking her blood pressure and performing similar basic tasks.
“There’s an assumption that there has to be some kind of direct, hands-on oversight for us to do our jobs, and that hasn’t been accurate for decades,” says Clayton, who practices at a clinic in Golden Valley, Minnesota. “We don’t assist. We provide care as part of a team.
Seeking to better understand and appreciate their profession, physician assistants are striving to rebrand themselves as “associate physicians.” Their national group officially changed “assistant” to “associate” in its name in May, morphing into the American Academy of Physician Associates. The group hopes state legislatures and regulators will legally enshrine the name change in statutes and rules. The total cost of the campaign, which began in 2018, will reach nearly $22 million, according to a consulting firm commissioned by the association.
Doctors push back
But renaming the PA name has raised blood pressure among doctors, who complain that some patients mistakenly assume a “doctor associate” is a young doctor – just like a lawyer who hasn’t yet made a partner is a associated. The head of the American Medical Association warned that the change “will undoubtedly confuse patients and is clearly an attempt to advance their quest for independent practice”. The American Osteopathic Association, another group that represents physicians, has accused physician assistants and other non-physician clinicians of trying “to obscure their credentials through title misappropriation.”
In medicine, seemingly innocuous title changes are fueled by endless turf wars between different levels of practitioners who jealously guard their professional prerogatives and the type of care they are authorized to perform. This year alone, the National Conference of State Legislatures listed 280 bills introduced in state houses to change scope of practice laws that define practice boundaries for nurses, physician assistants , pharmacists, paramedics, dental hygienists, optometrists and addiction counselors.
Lawmakers authorized dental hygienists in North Carolina to administer local anesthetics; authorized optometrists in Wyoming — who, unlike ophthalmologists, do not attend medical school — to use lasers and perform surgery under certain circumstances; and licensed Arkansas Certified Nurse Practitioners to practice independently. Meanwhile, the doctors’ lobby is aggressively fighting such proposals in state legislatures, accusing other disciplines of trying to incrementally catch up on things that doctors claim only they can do.
Physician assistants, as they are still legally called, have been granted greater autonomy over the years since 1967, when Duke University School of Medicine graduated four former Navy doctors as the first class of PAs from the country. Physician assistants today can perform many of the routine tasks of a primary care physician, such as examining patients, prescribing most types of medications, and ordering tests. In most states, all of this happens without needing a doctor’s approval or having a doctor in the same room or even in the same building.
Typically, a master’s degree in business administration takes two academic years to earn and includes approximately 2,000 hours of clinical work. More than 125,000 physician assistants were practicing last year in the United States; their median annual salary was $115,390. By comparison, family physicians typically attend four years of medical school and then complete a three-year medical residency, during which they complete approximately 10,000 hours. (Specialists spend even more time in residency.) The median annual salary for a family doctor in 2020 was $207,380.
APs aren’t the only specialists complaining
APs aren’t the only ones losing patience with their headlines. In August, the American Association of Nurse Anesthetists renamed itself the American Association of Nurse Anesthesiology – its third name since its inception in 1931. President Dina Velocci said the term “anesthetist” is confusing to the public and difficult to pronounce, even as she helps people pronounce each syllable. (It’s uh-NESS-thuh-tist in the US and indicates a registered nurse, who usually has a bachelor’s degree in nursing, and then received several additional years of education and training in anesthesia.)
The association’s new name is justified since “we do the lion’s share of all anesthetics in this country,” says Velocci. The legal title of the profession remains Certified Registered Nurse Anesthetist (CRNA). “I’m definitely not trying to say I’m a doctor,” Velocci says. “I clearly use ‘nurse’ in front.” Nevertheless, medical groups have condemned the association’s name change.
Likewise, the APs say there is no ulterior motive in changing their name. “Changing the title is really just to address this misperception that we’re just helping,” says Jennifer Orozco, PA association president and trustee of Rush University Medical Center in Chicago. “It won’t change what we do.”
They say the “assistant” not only confuses patients, but also state lawmakers and those who hire medical professionals. When Clayton recently testified before Minnesota lawmakers about a scope of practice bill, the lawmakers “simply couldn’t understand” the concept of an “assistant who doesn’t have a supervisor.” direct,” she said, adding that the message they gave her was, “You really need to do something about your title.”
The PA Association debated many names. Also-rans included “medical care practitioner” and the widely derided neologism “practitioner”. The “associate doctor” won, thanks to several advantages. It allowed AMs to continue to present themselves with the same initials, and it had been flirted with as an alternative throughout the profession’s history to distinguish the most highly qualified AMs from those with less training. The association even briefly used “associate” in its name for two years in the 1970s, and the Yale School of Medicine has offered an associate physician degree since the program opened in 1971.
Why frustrations run deeper than a job title
But a name change alone won’t solve the other downsides facing APs. In some states, physicians are required to meet regularly with physician assistants, periodically visit them in person if they work in a different location, and regularly review sample patient records. States generally place less oversight on nurse practitioners, who perform similar duties to physician assistants, making them more attractive to some employers. “We’ve heard from our fellow PAs that they’re posing as nurse practitioner jobs,” said April Stouder, associate director of the Duke Physician Assistant Program.
The physician lobby has opposed greater freedom for nurse practitioners, and many physicians are expressing similar concerns about patient safety if physician assistants are allowed to stray too far from physician oversight. Dr. Colene Arnold, a gynecologist in Newington, NH, began her medical career as a PA, practicing with little supervision. In retrospect, she says, “I didn’t recognize the seriousness of what I was seeing, and that’s scary.”
Dr. Kevin Klauer, CEO of the American Osteopathic Association, says misdiagnoses from PAs working solo are more likely than when a physician is involved. “If you go to Jiffy Lube and want an oil change and tire rotation, that’s what they’ll do,” he says. “Medicine is not like that.”
Orozco, the president of the PA association, says those concerns are overblown. “They will always collaborate with the doctors and really want to continue working in that team environment,” she says. Physicians should welcome physician assistants to help fill physician shortages in primary care, behavioral health and telemedicine and free up physicians to focus on complex cases, she adds.
“I can get a jet engine mechanic to change the tires on my car,” she says, “but do I need this every time?”
Kaiser Health News is a national newsroom and independent editorial program of the Kaiser Family Foundation. KHN is not affiliated with Kaiser Permanente.