What would Sir William Osler say?

As I was close to graduating from Rice University in 1976 and awaiting to hear from the University of Texas Health Science Center at San Antonio School of Medicine, my academic counselor informed me if I didn’t get accepted I could always apply to a relatively new physician assistant program at Baylor. That was my first exposure to a physician assistant program. Since that time, the programs and number of physician assistants have exploded.

The physician assistant program began as a means to allow more patient access to primary care in rural areas, with the physician assistant under the direct supervision of a licensed physician. If House Bill 1096 and its companion Senate Bill 800—bills presently under consideration—were to pass, they would allow a physician to hire up to six physician assistants or nurse practitioners working as far away as 75 miles from the physician. The supervising physician would never have to directly supervise the physician assistants and nurse practitioners, and would only have to review 10 percent of the medical charts. If enacted, the physician would never have to set foot at the alternate practice site. How can you adequately supervise someone if you are never there to do so? Instead of tightening restrictions on physician assistants, the Legislature is loosening restrictions.

The original concept has inexplicably transformed into not only primary care physicians hiring physician assistants, but specialists hiring them as well. Although this is legal and a good idea in theory, the manner in which physician assistants are being used by many physicians raises medical ethics questions. The consequences of these actions have now begun to be felt, and by now I’m sure nearly every doctor has his or her anecdotes.

From my own experience, I sent a patient to a local orthopedic surgeon to be evaluated for disc surgery. The patient was seen by his physician assistant, not the doctor. I then received a consult letter from the physician assistant—again, not the doctor. Not only was I insulted, but it was a waste of time and money for the patient.

One of my partner’s patients had congestive heart failure and was sent to a local cardiologist. The patient saw his physician assistant and was sent home on 12.5 mg of hydrochlorothiazide, after never seeing the cardiologist. Needless to say the patient saw no improvement. A month ago I went to great lengths to make sure a local cardiologist received the reports of a lab I had performed on a mutual patient. Last week when I asked the patient how his visit went with the cardiologist, the patient informed me he never saw the cardiologist, only the physician assistant.

Last year I saw the child of a patient who became frustrated when her pediatrician had not seen her child after two visits. On visit one, the child saw a physician assistant student. On visit two, the child saw a physician assistant. Because the child was not adequately evaluated and treated, the mother brought her to see me on visit three.

To show how far this problem has gone, I was made aware that a physician assistant of a primary care doctor referred an orthopedic case to the physician assistant of the orthopedist, not the specialist himself.

The anecdotes are numerous for multiple specialties, including gastroenterology and otorhinolaryngology. I have yet to understand why a specialist would employ a physician assistant to see referred patients when they have less training and experience than the very physicians who referred the patients. What qualifies a physician assistant to see specialty patients in the first place? Unfortunately, the answer lies with economics. A physician assistant allows a physician to be in more than one place at the same time. As a result, on average a physician will generate as much or more profit income than the amount of salary that has to be paid to a physician assistant.

A local student in good standing at UTHSC at San Antonio decided to drop out of medical school after her second year and become a physician assistant instead. Her rationale was she could make nearly as much money with less stress from the challenges of a traditional medical education and less responsibility. What does that say about the potential long-term impact to traditional medical education?

Are we reducing the functions of the Texas Medical Board? The Legislature has basically approved that people with minimal training can practice medicine without a license. Or are we increasing the responsibility of the medical board by having to reprimand physicians for lack of supervision of physician assistants, even though no laws are actually being broken? Four physicians were reprimanded for that very offense in the last issued report of the board. The board may become burdened with a whole new layer of oversight they are not equipped to handle because of sheer volume.

What is the financial impact of what we are doing by allowing such little restriction on the use of physician assistants? We hear every day about health care costs rising and we question what we must do to stem that trend. Yet we are authorizing physician assistants to order costly tests indiscriminately to aid them in clinical diagnosis to make up for their minimal training and lack of expertise. The irony is that it is okay, even under present law, to leave them unsupervised 80 percent of the time and only review 10 percent of their charts.

I would ask any physician if they would leave a third year medical student doing their clinical rotation with them unsupervised to diagnose, treat and prescribe, while only reviewing 10 percent of their charts! If the answer is no, then why not? They have the same training as a physician assistant, and actually more in the basic sciences. The Legislature is not the “Wizard of Oz,” who because he confers a certificate makes the recipient all-knowing.

Where are the Texas Medical Association and the Texas Academy of Family Physicians in this debate? Their voices appear to be muted. How many primary care physicians will be discouraged to re-certify in their specialty when there are providers doing the same thing they do without having had to endure the rigors of four years of medical school and the rigors of internship and residency?

What long-term impact will all of this have on medicine? Is this the best we can do to provide the quality medical care we strive to deliver to the citizens of the State of Texas? Is this good medicine? What would Sir William Osler say?