What can a Family Practitioner do that a PA-C cannot?

[usermike8500]

Specifically, is there anything a Family Physician can do that a PA-C cannot? I've worked under both types of professionals. They seem to have identical roles in the clinic.

The PA-C performed well-child/adult checks, pap smears, diabetes/HTN check-ups, diagnosed disease, prescribed drugs, ordered and interpreted tests and radiographs, and referred patients to specialists, all without any consultation or approval from a physician.

This left me wondering, is there anything that a Family Practice Physician can do that a PA-C cannot? I never saw the PA-C perform skin biopsies or insert intrauterine devices, so perhaps PAs can't do those procedures?

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[VA Hopeful Dr]

Specifically, is there anything a Family Physician can do that a PA-C cannot? I've worked under both types of professionals. They seem to have identical roles in the clinic.

The PA-C performed well-child/adult checks, pap smears, diabetes/HTN check-ups, diagnosed disease, prescribed drugs, ordered and interpreted tests and radiographs, and referred patients to specialists, all without any consultation or approval from a physician.

This left me wondering, is there anything that a Family Practice Physician can do that a PA-C cannot? I never saw the PA-C perform skin biopsies or insert intrauterine devices, so perhaps PAs can't do those procedures?

Practice medicine without supervision.

 

[deleted87716]

A PA can do anything that their supervising physician(s) let them do, and nothing more.

 

[deleted6669]

This left me wondering, is there anything that a Family Practice Physician can do that a PA-C cannot? I never saw the PA-C perform skin biopsies or insert intrauterine devices, so perhaps PAs can't do those procedures?

pa's can do biopsies and insert IUD's. procedures for the most part are monkey skills; see one, do one. that applies to almost anything outside of the o.r.
the difference isn't procedural, it's knowledge based. a family medicine doc has a much deeper understanding of medicine based on an extensive residency including inpatient rotations. in a clinic situation superficially they may look the same but the doc is typically drawing from a much wider experience base to make decisions than the pa. a family medicine doc can also work well as a hospitalist, something a new grad pa would find very difficult to do in light of the differences in training. this is why pa's are typically part of a care team and not solo providers with few exceptions.
I have a world of respect for a good family physician. the breadth of the specialty is huge. if I had gone back to medical school I would have aimed for a generalist position as a rural family medicine doc covering clinic, er, inpatients/icu, and low risk ob. one of my per diem gigs is at a rural facility that has several community docs who have in my mind the ideal job with a bit of everything thrown in to keep them interested in medicine. the family docs I don't understand are the ones who only see outpts and refer out anything even slightly out of the ordinary(all derm, all ob/gyn including yearly exams, all minor trauma and procedures, etc). that in my mind is a waste of a solid education.

 

[BrickHouseMD]

People like emedpa is the reason I will ALWAYS take a PA over an NP. This attitude of mutual respect and a healthy working relationship makes us coworkers and part of a team, instead of competitors for the same niche.

 

[militantcrna2]

as stated the real difference is in the skull sweat. family practice and internal medicine are the most underpaid under appreciated lot in medicine.....ever. they have to know or be able to recognize almost every thing out there, if not to treat at least to refer. most of the stories i hear reguarding np/pa is the inability to recognize that zebra from the horse.

 

[ghost dog]

A lot of these mid levels are undertrained.
The risk of unrecognized pathology going
undetected, particularly in overconfident, undertrained
personnel is a concern.

 

[aylwang]

get to be called Doctor,

I need a doctor, call me doctor, i need a doctor, i need a doctor to bring me back to life

 

[atstudent]

In many states, a PA or NP cannot clear a youth athlete after having suffered a concussion. Some states only allow a physician to do it; others (like Illinois once the bill is signed) allow only a physician or certified athletic trainer to clear an athlete to return to play.

 

[WFM18940]

If you're trying to choose between the route of an MD/DO vs. PA, then I would urge you to go for an MD/DO. A PA can see and treat patients, but won't have the autonomy and independence of a physician. Also, you'll be much better prepared to handle difficult and challenging patients because you'll have much more education/training/knowledge about pathophysiology and disease management.

 

[Toohotinvegas33]

I dont know if this is just a miami thing or what, but the PA's at my clinic cant write for benzo's or opiods.

Also, now that I have to train some of them, Ive seen a huge difference in medical knowledge. One i was working with had never done any inpatient medicine or heard of SIRS criteria and was going to graduate in a couple months...

 

[deleted6669]

I dont know if this is just a miami thing or what, but the PA's at my clinic cant write for benzo's or opiods.

that's just a florida thing. in many states pa's can write for anything sch 2-5.

 

[ghost dog]

that's just a florida thing. in many states pa's can write for anything sch 2-5.

That's frightening, considering a significant number of family MDs don't know how to script opioids appropriately.

How are PA's expected to do so?

This should definitely NOT be allowed.

 

[deleted6669]

That's frightening, considering a significant number of family MDs don't know how to script opioids appropriately.
How are PA's expected to do so?
This should definitely NOT be allowed.

for the most part those of us working outside of pain clinics do not write for long acting opiates like methadone/oxycontin, etc
most of it is fairly straight forward: broken wrist, looks painful, here's 15 vicodin to last you until you see ortho in a few days. I think my full year of graduate level pharmacolgy prepared me for that. I'm also guessing many family docs on this site would take offense to the beginning of your comment. you obviously have no idea what pa training entails.
There are pa's working with physicians as part of a team approach to pain medicine. there were many such places in a quick search like this:
http://spinecenterofdupage.com/physicians-spine-center-dupage-medical-group-naperville.htm

 

[tony montana]

That's frightening, considering a significant number of family MDs don't know how to script opioids appropriately.

Source? Einstein

 

[drift]

That's frightening, considering a significant number of family MDs don't know how to script opioids appropriately.

 

[ghost dog]

Source? Einstein

I see referrals from a significant number of family physicians for managing chronic non malignant pain.

A large number of these patients are either:

1. Prescribed opioids inappropriately (i.e. a minimal decrease in pain, despite stupid sized doses of opioids - no increase in function ).

2. Scripted opioids, with negative drug screens - with possible evidence of binging / drug diversion. The majority of said MDs have NEVER performed a urine drug screen (not one). It is a rare family MD indeed who does pill / patch counts.

3. Primary care MDs are scripting huge / stupid doses of narcotics.

Example: recent consult request: " Please see a reasonable patient of mine who has a past history of oxycontin addiction and is taking Fentanyl."

Really? This "reasonable" pt is taking 500 mcg Fentanyl. This MD has since lost his narc license. Was this MD performing UDS or patch counts?

Of course not.

Don't kid yourself - there is a lot of stupidity out there, med student. This loss of DEA licensure is more the exception than the rule in regards
to idiotic opioid scripting.

4. My favourite: scripting: 10 -14 percocet / day x years for constant pain. Slightly less than optimal.


The data out there for treating chronic non malignant pain is somewhat dubious. This data shows moderate benefit in reducing pain scores (a very subjective phenomenon ), but minimal for that of increasing function.

Opioids are a good tool, when used in the right population.


My original point is this : physician assistants should most definitely not be allowed to script controlled substances. This is extremely inappropriate.

 

[ghost dog]

for the most part those of us working outside of pain clinics do not write for long acting opiates like methadone/oxycontin, etc
most of it is fairly straight forward: broken wrist, looks painful, here's 15 vicodin to last you until you see ortho in a few days. I think my full year of graduate level pharmacolgy prepared me for that. I'm also guessing many family docs on this site would take offense to the beginning of your comment. you obviously have no idea what pa training entails.
There are pa's working with physicians as part of a team approach to pain medicine. there were many such places in a quick search like this:
http://spinecenterofdupage.com/physicians-spine-center-dupage-medical-group-naperville.htm

I really hope these P.A.'s are not titrating opioid doses. This requires a careful, considered approach. It is not "straight forward", as you
( inappropriately ) compare acute and chronic pain pathophysiology.

Patients with chronic pain require a multidisciplinary approach in managing their pain - not just an opioid monkey. If P.A's are simply refilling a script (and not changing the dose), I guess that would be reasonable - although they should be versed in the various protocols in monitoring.

Of note, pain clinics have gotten into trouble with PA's scripting narcs in the past.

 

[deleted6669]

My original point is this : physician assistants should most definitely not be allowed to script controlled substances. This is extremely inappropriate.

We can argue PA's in pain management settings but you would not allow pa's in em/fp/uc to write short courses of short acting narcs for defined pathology? ( my prior example of distal radius fx, rx #15 vicodin to last until ortho f/u). this is entirely reasonable.

 

[deleted6669]

Of note, pain clinics have gotten into trouble with PA's scripting narcs in the past.

ditto md's and np's.

 

[ghost dog]

We can argue PA's in pain management settings but you would not allow pa's in em/fp/uc to write short courses of short acting narcs for defined pathology? ( my prior example of distal radius fx, rx #15 vicodin to last until ortho f/u). this is entirely reasonable.

Your comparison between acute and chronic pain is inappropriate.

However, it is difficult to **** things up too much with scripting small supplies of short acting opioids in the acute setting.

Acute = most often fairly straight forward pathology.

Chronic = challenging problem (i.e. initial inciting insult may have resolved / superimposed psychogenic problem now present, or wholly causing issue, addiction issues may be present, secondary gain may be present, etc.).

When I first started managing chronic pain patients, I thought opioids were the best thing since sliced bread. With more experience (much of it hard experience) , I learned this simply wasn't the case. It is simply not fair, or realistic, to expect practioners with less training to perform detailed evaluations of a population with such complex needs. This will lead to trouble.

I have seen (by way of my referrals) that many family physicians have significant trouble managing this population. I really can not envision how a lesser trained mid level provider could do any better.

Please explain how the above is not the case.

 

[deleted6669]

I wasn't confusing anything.
you said pa's should not script narcs AT ALL.
I gave examples of pa's writing short and long term narcotic regimens and pointed out that the vast majority of pa's don't write for long acting narcs. then I gave an example of pa's who do who work for pain clinics.
do YOU understand now.

 

[ghost dog]

ditto md's and np's.

Yes, and this was part of my point.

If family MD's are experiencing problems with opioid related management, how are lesser trained PA's doing in this sphere?

You are making my point for me.

 

[ghost dog]

I wasn't confusing anything.
you said pa's should not script narcs AT ALL.
I gave examples of pa's writing short and long term narcotic regimens and pointed out that the vast majority of pa's don't write for long acting narcs. then I gave an example of pa's who do who work for pain clinics.
do YOU understand now.

See my above detailed explanation, with this modification:

PA's should not be initiating or titrating long acting opioids; they are not adequately trained for this endeavour.

This is a disturbing trend in healthcare.

Another such trend is that of PA's performing interventional pain procedures. A very poorly thought out idea.

Nuff said.

 

[deleted6669]

If family MD's are experiencing problems with opioid related management, how are lesser trained PA's doing in this sphere?
.

how about relevant cme above and beyond their initial schooling?
pa's can attend pain medicine conferences just like docs and learn all they need to know through that avenue.

 

[tony montana]

I see referrals from a significant number of family physicians for managing chronic non malignant pain.

So your source to say that "a significant number of family MDs don't know how to script opioids appropriately" is purely anecdotal...


How cute!

 

[deleted87716]

You also have options that primary care does not...(most importantly) the ability to fire patients who don't follow your rules.

Primary care physicians can also dismiss patients who don't follow the rules.

 

[ghost dog]

Primary care physicians can also dismiss patients who don't follow the rules.

How very true.

However, if a patient doesn't follow the rules / breaks the opioid contract - they don't necessarily have to be discharged from the practice (unless
they really piss you off).

In my experience, I don't usually see family MDs ordering:

1. Urine drug screens.

2. Performing pill / patch counts.

3. Checking to make sure patients aren't coming in early for narcs, and counting out the days / using a calendar before the next script is due.

One of the above posters pointed out that the majority of chronic pain is managed by family MDs; this is also very true. However, it should be realized that opioids aren't a magic bullet. Some patients can be very manipulative. I was very surprised by the result of 1-3 when I first started doing the above. This is strongly recommended.

A few comments on the above poster's points:

1. If you believe a patient is not benefiting from opioids, and you are now scripting them, they should be stopped. Everyone has experienced this problem. I see this problem all the time, and recommend either a taper (via the current drug or methadone). It doesn't eliminate your responsibility just because you didn't start this med.

2. From the tone of the above post, it sounds like you are trying to advocate for the patient. However, an inappropriate opioid script is not patient advocacy; it is the exact opposite.

NOTE: A family physician colleague and (good friend of mine) just had a patient of his overdose and die on Hydromorph Contin, which she was taking for intractable chronic headache. This class of medication is not risk free, and should be treated with respect. Word to the wise.

By the way: In addition to managing chronic pain, I am also a family physician by training. I know exactly what it's like to practice this type of medicine. Family doctors are in an ideal position to manage chronic pain in their patients, as they usually know them the best; however, they need to follow the recommended guidelines.

 

[Kingfisher]

Delivered 3 babies yesterday. Never seen a PA do that (nurse midwife however...).

 

[deleted6669]

Delivered 3 babies yesterday. Never seen a PA do that (nurse midwife however...).

http://forums.studentdoctor.net/showthread.php?t=840820

SEE POST #33. RECENTLY DISCUSSED. SHORT VERSION: PA'S DELIVER BABIES.

 

[jwk]

Delivered 3 babies yesterday. Never seen a PA do that (nurse midwife however...).

No offense intended, but this is yet another example of how the real world of private practice differs drastically from the sheltered halls of academia. You should preface your opinion with "In my limited experience within my residency....."

 

[jwk]

Your comparison between acute and chronic pain is inappropriate.

However, it is difficult to **** things up too much with scripting small supplies of short acting opioids in the acute setting.

Acute = most often fairly straight forward pathology.

Chronic = challenging problem (i.e. initial inciting insult may have resolved / superimposed psychogenic problem now present, or wholly causing issue, addiction issues may be present, secondary gain may be present, etc.).

When I first started managing chronic pain patients, I thought opioids were the best thing since sliced bread. With more experience (much of it hard experience) , I learned this simply wasn't the case. It is simply not fair, or realistic, to expect practioners with less training to perform detailed evaluations of a population with such complex needs. This will lead to trouble.

I have seen (by way of my referrals) that many family physicians have significant trouble managing this population. I really can not envision how a lesser trained mid level provider could do any better.

Please explain how the above is not the case.

You really don't pay attention to responses much, do you?

And it makes me wonder what specialty you're in as well. If you AT ANY TIME thought opiods were the best thing since sliced bread, it would give me pause. Just saying...

 

[ghost dog]

You really don't pay attention to responses much, do you?

And it makes me wonder what specialty you're in as well. If you AT ANY TIME thought opiods were the best thing since sliced bread, it would give me pause. Just saying...

Another mid level heard from.

Evidently, you are the one who failed to read posts, as I have previously indicated that my original training is that of family medicine.

Here's a little continuing medical education for you, gratis (no need to thank me): there is a significant body of clinicians who believe in prescribing opioids (some scripting opioids in significant amounts) for the management of chronic non-malignant pain. Heading this charge are physicians and researchers ; some names include Dr. Steven Passik and Dr. Charles Argoff:

http://www.prescriberesponsibly.com/experts/passik

There is a concept known as the watchful Morphine equivalent daily dose; in my experience, patients who exceed such a dose are usually not those who have difficult to treat / intractable pain. They are those who have been titrated up to such levels by inexperienced clinicians. Rather, they are usually opioid non responders, and should not have been escalated to said levels in the first place.

My point here is this: over the past decade, clinical thinking has started to lean towards treating the chronic non cancer pain with long acting opioids. Indeed, the academic community has encouraged such an approach (see above), and the chronic pain community is now reconsidering this treatment paradigm. By no means at all, was it
" just myself " that considered opioids the magic bullet. Many chronic pain talks that I attended (paid for usually by the pharmacetical industry) encouraged such an approach.

We are now learning, more and more, that this one size fits all treatment is unwise.


A relevant example that sticks out in my mind: frail elderly gentleman / multiple medical problems and lumbar spinal stenosis with glaringly obvious opioid failure. Accidental opioid overdose: he required a naloxone drip while in hospital, and discharged home on a smaller dose.

WHY???

I reassessed him, and stopped this opioid. I still don't know why he was d/c'd home on opioids by the acute pain care team in hospital. He informed me he obtained zero relief with this medication. Stupid, stupid.


As I believe you are a CRNA, I would be very interested in knowing whether:

1. CRNAs function independently in chronic pain clinics (i.e. performing epidurals, neural blockade, etc.)?

2. Do CRNAs initiate and titrate long acting opioids in pain clinics?

I am unfamiliar with these mid level practice patterns, as I am located in Canada.

 

[jwk]

Another mid level heard from.

Evidently, you are the one who failed to read posts, as I have previously indicated that my original training is that of family medicine.

Here's a little continuing medical education for you, gratis (no need to thank me): there is a significant body of clinicians who believe in prescribing opioids (some scripting opioids in significant amounts) for the management of chronic non-malignant pain. Heading this charge are physicians and researchers ; some names include Dr. Steven Passik and Dr. Charles Argoff:

http://www.prescriberesponsibly.com/experts/passik

There is a concept known as the watchful Morphine equivalent daily dose; in my experience, patients who exceed such a dose are usually not those who have difficult to treat / intractable pain. They are those who have been titrated up to such levels by inexperienced clinicians. Rather, they are usually opioid non responders, and should not have been escalated to said levels in the first place.

My point here is this: over the past decade, clinical thinking has started to lean towards treating the chronic non cancer pain with long acting opioids. Indeed, the academic community has encouraged such an approach (see above), and the chronic pain community is now reconsidering this treatment paradigm. By no means at all, was it
" just myself " that considered opioids the magic bullet. Many chronic pain talks that I attended (paid for usually by the pharmacetical industry) encouraged such an approach.

We are now learning, more and more, that this one size fits all treatment is unwise.


A relevant example that sticks out in my mind: frail elderly gentleman / multiple medical problems and lumbar spinal stenosis with glaringly obvious opioid failure. Accidental opioid overdose: he required a naloxone drip while in hospital, and discharged home on a smaller dose.

WHY???

I reassessed him, and stopped this opioid. I still don't know why he was d/c'd home on opioids by the acute pain care team in hospital. He informed me he obtained zero relief with this medication. Stupid, stupid.


As I believe you are a CRNA, I would be very interested in knowing whether:

1. CRNAs function independently in chronic pain clinics (i.e. performing epidurals, neural blockade, etc.)?

2. Do CRNAs initiate and titrate long acting opioids in pain clinics?

I am unfamiliar with these mid level practice patterns, as I am located in Canada.

I looked through your other posts on this thread. I didn't see anything that you were an FP, just that you talked a lot about the problems other FP's have treating chronic pain. Unlike you I put my credentials in my profile where it's easy to look up - I'm an AA, not a CRNA.

CRNA's have no business being involved in chronic pain management, nor do PA's for that matter. Chronic pain patients are best treated by pain management fellowship-trained physicians, not physician or mid-level practitioners who literally attend a couple of weekend courses and then claim to be a "Pain Management Specialist". Many of those, particularly generalist physicians with unlimited prescriptive authority, have basically turned into little more than pill mills, with all the deservedly negative press that accompanies them.

 

[ghost dog]

I looked through your other posts on this thread. I didn't see anything that you were an FP, just that you talked a lot about the problems other FP's have treating chronic pain. Unlike you I put my credentials in my profile where it's easy to look up - I'm an AA, not a CRNA.

CRNA's have no business being involved in chronic pain management, nor do PA's for that matter. Chronic pain patients are best treated by pain management fellowship-trained physicians, not physician or mid-level practitioners who literally attend a couple of weekend courses and then claim to be a "Pain Management Specialist". Many of those, particularly generalist physicians with unlimited prescriptive authority, have basically turned into little more than pill mills, with all the deservedly negative press that accompanies them.

Indeed, I could not agree more.

However, you do need to brush up a tad on your reading skills. I indicated that my original training was that of family medicine in post #29.

I have also , repeatedly, emphasized that opioids are not a panacea. Apparently this has eluded you ?

I do indeed have pain medicine training. I received an additional 3 years training following my FM residency.

 

[EMDream]

As an hospitalist PA I absolutely loathe prescribing narcotics other than literally a handful for acute PROVEN pain sources and with negative urine tox screens. Our er does not routinely drug screen people with pain related complaints and i think anyone who we are considering giving narcotics too should be screened with a urine or blood tox before the first dose is administered ( it doesn't have to result but at least we'll have theninfo in hand before the next dose) except in emergencies. Drug seeking behavior is rampant in both inpatient and outpatient primary care settings. I will be asking my husband how often he performs patch/pill counts at his inner city clinic that is as you can imagine a popular chronic pain management site ie drug diversion central. I am exhausted by chronic pain patients to be honest and am more than happy to refer to pain management and agree opioid's have established very role in providing any real benefit to restoring function in most patients. I do not think that scheduled drugs should be restricted to only MDs but there should be stricter parameters in which we are allowed to prescribe ie documented pill counts, pharmacy confirmation of dispensing, tox screens so we are Ed to take an active role in drug diversion prevention.

Thank you for your insights.

One small last thing, do you not think your insight could be imparted to a midlevel you train yourself to prescribe appropriately vs

How very true.

However, if a patient doesn't follow the rules / breaks the opioid contract - they don't necessarily have to be discharged from the practice (unless
they really piss you off).

In my experience, I don't usually see family MDs ordering:

1. Urine drug screens.

2. Performing pill / patch counts.

3. Checking to make sure patients aren't coming in early for narcs, and counting out the days / using a calendar before the next script is due.

One of the above posters pointed out that the majority of chronic pain is managed by family MDs; this is also very true. However, it should be realized that opioids aren't a magic bullet. Some patients can be very manipulative. I was very surprised by the result of 1-3 when I first started doing the above. This is strongly recommended.

A few comments on the above poster's points:

1. If you believe a patient is not benefiting from opioids, and you are now scripting them, they should be stopped. Everyone has experienced this problem. I see this problem all the time, and recommend either a taper (via the current drug or methadone). It doesn't eliminate your responsibility just because you didn't start this med.

2. From the tone of the above post, it sounds like you are trying to advocate for the patient. However, an inappropriate opioid script is not patient advocacy; it is the exact opposite.

NOTE: A family physician colleague and (good friend of mine) just had a patient of his overdose and die on Hydromorph Contin, which she was taking for intractable chronic headache. This class of medication is not risk free, and should be treated with respect. Word to the wise.

By the way: In addition to managing chronic pain, I am also a family physician by training. I know exactly what it's like to practice this type of medicine. Family doctors are in an ideal position to manage chronic pain in their patients, as they usually know them the best; however, they need to follow the recommended guidelines.

 

[ghost dog]

As an hospitalist PA I absolutely loathe prescribing narcotics other than literally a handful for acute PROVEN pain sources and with negative urine tox screens. Our er does not routinely drug screen people with pain related complaints and i think anyone who we are considering giving narcotics too should be screened with a urine or blood tox before the first dose is administered ( it doesn't have to result but at least we'll have theninfo in hand before the next dose) except in emergencies. Drug seeking behavior is rampant in both inpatient and outpatient primary care settings. I will be asking my husband how often he performs patch/pill counts at his inner city clinic that is as you can imagine a popular chronic pain management site ie drug diversion central. I am exhausted by chronic pain patients to be honest and am more than happy to refer to pain management and agree opioid's have established very role in providing any real benefit to restoring function in most patients. I do not think that scheduled drugs should be restricted to only MDs but there should be stricter parameters in which we are allowed to prescribe ie documented pill counts, pharmacy confirmation of dispensing, tox screens so we are Ed to take an active role in drug diversion prevention.

Thank you for your insights.

One small last thing, do you not think your insight could be imparted to a midlevel you train yourself to prescribe appropriately vs

You bring up a few points here:

1. Acute pain management is a different beast altogether from that of chronic pain tx. Even if a patient has a co-morbid addiction, they still have the right to receive management for an acute pain condition (although it does complicate matters).

2. I do not agree with mid levels managing chronic pain with opioids, for the reasons I have mentioned above. While it may seem like a fairly straightforward endeavour it only seems that way. It is not. Following an algorithmic approach to such a complicated problem can land an
inexperienced practioner in trouble.

Example: following the paradigm that "opioids have no celing dose." I have seen countless referrals with patients who are on high dose long acting opioids with minimal benefit. Assessing this population is not straightforward.