Physician assistants prefer ‘associate.’ Doctors suspect a power grab : Shots

After 23 years as a physician assistant, Leslie Clayton remains rankled by one facet of her vocation: its title. Specifically, the word “assistant.”

Patients have asked if she’s heading to medical school or in the middle of it. The term confounded even her family, she says: It took years for her parents to understand she does more than take blood pressure and perform similar basic tasks.

“There is an assumption that there has to be some sort of direct, hands-on oversight for us to do our work, and that’s not been accurate for decades,” says Clayton, who practices at a clinic in Golden Valley, Minn. “We don’t assist. We provide care as part of a team.”

Seeking greater understanding for and appreciation of their profession, physician assistants are pushing to rebrand themselves as “physician associates.” Their national group formally replaced “assistant” with “associate” in its name in May, transforming into the American Academy of Physician Associates. The group hopes state legislatures and regulatory bodies 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 hired by the association.

Doctors are pushing back

But rechristening the PA name has spiked the blood pressure of physicians, who complain that some patients will wrongly assume a “physician associate” is a junior doctor — much as an attorney who has not yet made partner is an associate. The head of the American Medical Association has warned that the change “will undoubtedly confuse patients and is clearly an attempt to advance their pursuit toward independent practice.” The American Osteopathic Association, another group that represents doctors, accused PAs and other nonphysician clinicians of trying “to obfuscate their credentials through title misappropriation.”

In medicine, seemingly innocuous title changes are inflamed by the unending turf wars between various levels of practitioners who jealously guard their professional prerogatives and the kind of care they are authorized to perform. Just this year, the National Conference of State Legislatures catalogued 280 bills introduced in statehouses to modify scope-of-practice laws that set the practice boundaries of nurses, physician assistants, pharmacists, paramedics, dental hygienists, optometrists and addiction counselors.

Lawmakers allowed North Carolina dental hygienists to administer local anesthetics; permitted Wyoming optometrists — who, unlike ophthalmologists, do not attend medical school — to use lasers and perform surgeries in certain circumstances; and authorized Arkansas certified nurse practitioners to practice independently. Meanwhile, the physicians’ lobby aggressively fights these kinds of proposals in state legislatures, accusing other disciplines of trying to incrementally horn in on things that doctors claim only they are competent to do.

Physician assistants, as they are still legally called, have been steadily granted greater autonomy over the years since 1967, when the Duke University School of Medicine graduated four former Navy medics as the nation’s first class of PAs. Today PAs can perform many of the routine tasks of a primary care doctor, such as examining patients, prescribing most kinds of medications and ordering tests. In most states, all this happens without the need for a physician’s signoff or having a doctor in the same room or even the same building.

Generally, a PA master’s degree takes two academic years to earn and includes about 2,000 hours of clinical work. More than 125,000 PAs were practicing last year in the U.S.; their median annual pay was $115,390. By comparison, family physicians usually attend four years of medical school and then do a three-year medical residency, during which they clock about 10,000 hours. (Specialists spend even more time in residencies.) The median annual pay for a family physician in 2020 was $207,380.

PAs aren’t the only specialists complaining

PAs aren’t alone in losing patience with their titles. In August, the American Association of Nurse Anesthetists renamed itself the American Association of Nurse Anesthesiology — its third name since it was founded in 1931. President Dina Velocci said the term “anesthetist” baffles the public and is hard to pronounce, even when she helps people sound out each syllable. (It’s uh-NESS-thuh-tist in the U.S. and indicates a registered nurse, who usually has a bachelor’s degree in nursing, and has then received several more years of education and training in anesthesia.)

The association’s new name is justified since “we’re doing the lion’s share of all the anesthetics in this country,” Velocci says. The legal title for the profession remains certified registered nurse anesthetist (CRNA). “I’m definitely not trying to say I’m a physician,” Velocci says. “I’m clearly using ‘nurse’ in front of it.” Nonetheless, physicians’ groups have condemned the association’s name change.

Likewise, the PAs say there’s no ulterior motive in altering their name. “Changing the title is really just to address that misperception that we only assist,” says Jennifer Orozco, president of the PA association and an administrator at Rush University Medical Center in Chicago. “It won’t change what we do.”

They say “assistant” confuses not just patients but also state lawmakers and those who hire medical professionals. When Clayton recently testified before Minnesota legislators about a scope-of-practice bill, lawmakers “just couldn’t get their heads around” the concept of “an assistant who doesn’t have a direct supervisor,” she says, adding that the message they gave her was, “You guys 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 “praxician.” “Physician associate” won out, thanks to several advantages. It allowed PAs to continue to introduce themselves with the same initials, and it had been flirted with as an alternative throughout the profession’s history to distinguish the most highly trained PAs from those with less training. The association even briefly used “associate” in its name for two years in the 1970s, and Yale School of Medicine has offered a physician associate degree since the program opened in 1971.

Why the frustrations run deeper than a job title

But a name change alone won’t resolve other disadvantages PAs face. In some states, doctors are required to meet regularly with PAs, periodically visit them in person if they work at a different location and review sample patient charts on a recurring basis. States generally mandate less oversight for nurse practitioners, who perform jobs similar to those of PAs, making them more appealing to some employers. “We’ve heard from our PA colleagues that they’re getting passed over for jobs for nurse practitioners,” says April Stouder, associate director of the Duke Physician Assistant Program.

The physicians’ lobby has opposed greater liberty for nurse practitioners, and many doctors voice similar concerns about patient safety if PAs are allowed to drift too far from physician oversight. Dr. Colene Arnold, a gynecologist in Newington, N.H., started her medical career as a PA, practicing with little supervision. In retrospect, she says, “I didn’t recognize the severity of what I was seeing, and that’s scary.”

Dr. Kevin Klauer, CEO of the American Osteopathic Association, says misdiagnoses by PAs working solo are more likely than when a physician is involved. “If you go to Jiffy Lube and you want an oil change and a tire rotation, that’s what they’re going to do,” he says. “Medicine is not like that.”

Orozco, the PA association president, says such anxieties are overblown. “They will always collaborate with physicians and really want to keep working in that team-based environment,” she says. Doctors should welcome PAs to help fill physician shortages in primary care, behavioral health and telemedicine and free up doctors to focus on complex cases, she adds.

“I can have a jet-engine mechanic change the tires on my car,” she says, “but do I need that every single time?”

Kaiser Health News is a national newsroom and editorially independent program of the Kaiser Family Foundation. KHN is not affiliated with Kaiser Permanente.