Secondary Logo

Journal Logo

Musings: Blog of the JAAPA Editorial Board


Blog of the JAAPA editorial board.

Monday, November 2, 2015

Contemporary medical practice: The best of times, the worst of times

Brian T. Maurer, PA-C


It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, it was the season of Light, it was the season of Darkness, it was the spring of hope, it was the winter of despair, we had everything before us, we had nothing before us, we were all going direct to Heaven, we were all going direct the other way—in short, the period was so far like the present period, that some of its noisiest authorities insisted on its being received, for good or for evil, in the superlative degree of comparison only.—Charles Dickens, A Tale of Two Cities


Back in 1983 during my time in graduate school, I took a course titled Community Psychology. Admittedly, I remember little from it; but one concept has stuck with me over the decades of my subsequent career: There are always resources available in the community; you merely need to seek them out.

The latest resource available to members of the PA community made its debut at this year’s annual AAPA conference in San Francisco. An online open-access forum for PAs, the Huddle, became an overnight phenomenon. Folks were signing up left and right, introducing themselves to the community at large and starting all sorts of discussion threads apropos PA practice. Students posted requests for advice on how to make it through the demands of a PA education, when to start looking for their first job, and tips in studying for the PANCE; while veteran PAs logged in to voice concerns about diverse topics such as credentialing and recertification, relocating to other areas of the country, the best way to become certified in ultrasonography, strategies on how to deal with competition from our NP colleagues, suggestions on the best way to move into administration, or how to go about transitioning to a new field in medical practice. As near as I could tell, many of the recommendations and much of the advice seemed to be spot on.

My Community Psychology professor was right: resources always are available in the community; one merely needs to seek them out. The Huddle has proven itself to be a great resource venue for members of the PA profession. Modern electronic technology and social media made it all happen. For practicing PAs, it’s been the best of times.

Unfortunately, it’s also been the worst of times, for any number of reasons. The same electronic technology that gave us those unlimited resources in the Huddle has also promised to undermine the efficiency of medical practice. The electronic medical record (EMR) has not proven itself to be the boon it was promised to be. Entering data into the individual patient’s health record has become a tedious chore for most clinicians. By some accounts it has decreased productivity 30% and added hours of extra work to the exhausted clinician’s workday. When the system goes down, everything stops: data can not be accessed. When the system is up and running it works like a charm—except most EMR systems are incompatible with each other.

Frankly, I’m not so sure that these systems have improved healthcare delivery to any great extent. If anything, the laptop/notebook/tablet has certainly interfered with the caring clinician-patient encounter. When a newly-minted clinician asked for the salient points regarding a mature patient’s menses, the exasperated patient jumped up and thrust her hands between the clinician’s eyes and the electronic screen on his lap. “Look at me,” she cried, “I’m 65 years old! Do I look like I’m still having my period?”

Recently I was asked to precept an NP student during his ambulatory pediatric rotation. As it turned out this fellow had been practicing as a chiropractor for the past 10 years. He elected to complete his nursing degree and NP program online, thinking to incorporate the equivalent of primary care into his chiropractic practice. “In this state, advance practice nurses can move from collaborative to independent practice in 3 years,” he told me. “PAs are required to maintain supervisory practice for their entire careers.” His words cut deep.

Shortly after this conversation, I stopped off to chat with an NP at a retail clinic in one of the local commercial pharmacies. She was very cordial when she learned that I was in my 36th year of practice as a PA. “You guys are so much better trained that we are,” she told me. “So much of what I encounter here is outside my scope of practice, so I end up referring nearly everything out.” Then she made a telling remark. “It’s too bad PAs can’t practice in a venue like this,” she said. “They always have to work under direct supervision. None of the doctors want to have to sign off on a PA’s charts; they’ve got enough of their own work to do to keep up with their incentives.”

How right she was! Her words were substantiated in a discussion thread in the Huddle. PAs are being replaced by NPs and APRNs exactly for that reason. In spite of what many might refer to as our superior training in the medical model, by definition PAs are still required to work under supervision—at least on paper.

So yes; lately, it’s been the best of times, it’s been the worst of times. The words of Charles Dickens ring as true today as when he first penned them nearly two centuries ago. I wonder how it will all shake out in our time.

Brian T. Maurer has practiced general pediatrics for more than 30 years. He is the author of Patients Are a Virtue and blogs at The views expressed in this blog post are those of the author and may not reflect AAPA policies. 


Share this blog post on Facebook or Twitter using the buttons below!

Facebook Twitter