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One physician's perspective on the physician-PA relationship

Gradison, Margaret MD, MHS-CL, FAAFP

Journal of the American Academy of Physician Assistants: March 2017 - Volume 30 - Issue 3 - p 8–10
doi: 10.1097/01.JAA.0000512241.66494.5c

Margaret Gradison is a professor in the Department of Community and Family Medicine and medical director of the PA program at Duke University Medical Center in Durham, N.C. The author has disclosed no potential conflicts of interest, financial or otherwise.

Ruth Ballweg, MPA, PA; Reamer L. Bushardt, PharmD, PA-C, DFAAPA; and Tanya Gregory, PhD, anniversary series editors





When I was asked to write about the physician-PA relationship, I was not sure how best to approach the topic. This topic is not only important to me but one I have spoken and written about on many occasions. As the 50th anniversary of the PA profession approaches, let me respond in a personal way. My experience parallels the remarkable growth and changes within the PA profession throughout the country.

My path to learning about and working with PAs has been a journey with interesting twists and turns. I would love to profess that I have had knowledge of and experience with PAs most of my life, but this is simply not true. I grew up and went to medical school in Cincinnati, Ohio, in the 1970s. The PA profession was unknown to me at that time.

I had the opportunity to learn about PAs as a resident in family medicine at the University of Colorado Health Sciences Center in the early 1980s. I trained with and learned from students and faculty who were part of the child health associate program. They were integral members of the team on my pediatric rotations, and I developed high regard for their knowledge and skills. This respect and support was modeled by my attending physicians, which made a deep impression on me. Today I strive to demonstrate this respect and support as an attending physician in my interactions with learners and colleagues from a variety of health professions.

While in Colorado, I owned a private practice with another family physician in which we employed PAs. They were invaluable and integral members of our small practice. We each had our own areas of interest and expertise. Not only did our PA colleagues provide high-quality care, but we learned from each other in a collaborative way. For example, Tony Moreno, PA-C, had been a surgical PA before working for us. His suturing skills and surgical experience were far beyond ours, so he cared for most of the patients in our practice who needed these skills. This was particularly valuable because of the number of chainsaw accidents we saw (many people in our area heated their homes with wood). In addition, Tony gave me pointers on how to improve my suturing skills in the event he was not available when these patients needed care.

I then worked for a brief time in Indianapolis, where I was disappointed to find that there were no PAs at the academic medical center. This situation apparently was a result of limitations imposed by the state legislature at the time.

After this, I settled down in North Carolina, where I have been on the faculty at Duke University School of Medicine for the past 22 years and have had the honor of being the medical director of the Duke PA program for the past 9 years. I have been fortunate to work with incredibly skilled and dedicated PAs.

The variation in the role (or absence) of PAs from state to state throughout my career has been remarkable. Having been in settings with and without PAs, I have observed that the patients and other members of the healthcare team are enriched by PAs. My personal experience has been not only as an educator and clinician but also as a patient. On more than one occasion, the PA treating me was correct about my diagnosis and the physician was not. I am pleased to say that discussions between the PA and supervising physician in these situations were respectful and collaborative.

So what makes a good relationship between a PA and physician? I believe it is the same thing that makes a good relationship between any two (or more) people. Physicians and PAs are smart, dedicated, and hardworking. Their relationship works best when it is built on mutual respect. I believe we can learn from each other regardless of our education and training; we are all striving to continue to learn and improve our knowledge and skills. As with other relationships in life, respect and support are needed, as is ongoing honest and open communication. As with most other relationships, this one requires give and take so that it can mature over time.

I have also observed dysfunctional relationships between physicians and PAs. Some physicians are dictatorial, hierarchical, unsupportive, or use PAs as medical assistants. I have also seen PAs who act like cowboys (not asking for assistance when they should), operate beyond the scope of practice of their collaborating physician, or fail to be an active team member. Collaborative relationships may be inhibited by differences in personality and/or expectations as well as by systems and financial issues.

I counsel my students about the importance of this relationship when they are interviewing for jobs or are having conflicts with their supervising physicians. For example, one of our recent graduates found herself in a relationship in which she was very vulnerable. Her supervising physician left to operate and was unavailable by phone or pager a couple of days a week. He complimented her on her intelligence and skills, and he told her that there were no circumstances in which contacting him would be necessary because she was so smart and capable. Needless to say, I advised her to speak with him and consider other employment options.

Above all, PAs and physicians are here for our patients. There are fewer interpersonal issues, conflicts of interest, or difficulties with our relationships as long as we all value and give top priority to our patients (and students, for those of us in education).

I have been fortunate throughout my career to work with, be the supervising physician for, and educate a number of highly skilled PAs. I continue to learn from my PA colleagues and value our ongoing collaboration. Many changes in healthcare over the years have made my role as a family physician much more challenging and less rewarding. I can say unequivocally, however, that working with my PA colleagues (who are finally empowered to practice in all states!) has been one of the most positive aspects of practicing medicine. And most important to us all, our patients benefit greatly from the care provided by PAs.

Copyright © 2017 American Academy of Physician Assistants