Like many of my contemporary colleagues, I've had the privilege of watching our profession evolve from its humble beginnings to near universal acceptance. Over the past three decades, every state has enacted legislation to enable PA practice. A second major milestone, the granting of prescriptive privilege, has served to solidify the recognition of PAs as bona fide clinicians.
Such was not always the case. Thirty years ago, as a new graduate working my first job at an inner city health clinic, I had to track down my supervising physician each time I needed to have a prescription signed. Later, I was given presigned blank prescriptions to make the process less cumbersome. Even though I was the one who had evaluated the patient, I still was forbidden to sign my name to the prescription for pharmacologic treatment that I had drafted. The implication was that somehow I wasn't competent enough to prescribe the appropriate drug without direct oversight.
Things have changed quite a bit since then. With the implementation of both federal and state controlled substance registration for PAs, we are now granted autonomy to write for the gamut of pharmaceutical substances. This has not gone unnoticed by the pharmaceutical industry, whose representatives detail clinicians daily on the merits of the latest branded drugs to hit the market. The ability to prescribe has added power and prestige to the ranks of our profession.
Like physicians, PAs are trained in the medical model: diagnosis, prescription. First formulate the diagnosis; then prescribe the appropriate drug. This is so ingrained in us through our training that most clinicians never question it. After all, this is what we do in evaluating patients every day-we diagnose; we prescribe.
Sir William Osler, the great Canadian physician, teacher, and humanist, had something to say about this process. One hundred years ago, Osler declared that “diagnosis, not drugging, is our chief weapon of offense. Lack of systematic personal training in the methods of the recognition of disease leads to the misapplication of remedies, [and] to long courses of treatment when treatment is useless….”1
Osler also had something to say about prescribing drugs and the pharmaceutical industry: “Man has a craving for medicine…. [T]he desire to take medicine is one feature which distinguishes man, the animal, from his fellow creatures…. It is really one of the most serious difficulties with which we have to contend. Even in minor ailments, which would yield to dieting or to simple home remedies, the doctor's visit is not thought to be complete without the prescription.”1
“To modern pharmacy we owe much, and to pharmaceutical methods we shall owe much more in the future, but… pharmacy in this form threatens to become a huge parasite, eating the vitals of the body medical.”1
True to Osler's observations, prescription drugs have become the mainstay of contemporary medical treatment. Patients expect us to prescribe medication for their ills, and we in turn seem happy to oblige. We operate under the notion that, if we can arrive at a proper diagnosis and prescribe the appropriate drugs, the patient will get better.
Over the years, as I performed the clinical role I had been trained to do, I discovered that many of my patients, perhaps the majority of them, didn't seem to get well. Many had difficulty coping with their disease. One day I realized that, despite all my training, knowledge and expertise, ultimately there seemed to be little that I could do medically to improve the lives of my patients.
On the advice of a colleague, I attended a conference on the medical humanities and humane medical practice. One of the speakers—a layman from Great Britain—suggested to us clinicians that we might consider offering our patients a part of ourselves instead of just a prescription for a drug. To me this somehow seemed a revelation.
That day, Osler's words reverberated inside my head: “The practice of medicine is an art, not a trade: a calling, not a business, a calling in which your heart will be exercised equally with your head. Often the best part of your work will have nothing to do with potions and powders….”1 From then on, I resolved to incorporate the tenets of humane medicine into my daily practice.
Like my colleagues, I still write prescriptions, of course. I still manage patients with acne, aeroallergies, asthma, eczema, ear infections—the gamut of bread and butter pediatrics. The difference is that now I strive to listen to their stories, to discern the meaning behind their words, to offer them a part of myself in the interaction.
After three decades of medical practice, I'm not so much interested in potions or powders as I am in my patients as persons. I still can't cure many of their ailments, but I've learned how to lead some of them gently down the path toward healing.
That's a prescription that we can all feel good about handing out. JAAPA