Physician Assistants/Extenders: Licensed Practitioners with Minimal Training

TASA ID: 3797

The current difficulty with escalating medical costs has resulted in politician/legislators looking to control costs chiefly at the expense of physicians. While their endeavors have been fruitless in terms of reigning-in ever increasing costs, they have had a significant impact on the delivery of medical care and on the perceptions and expectations of the public. Furthermore, the ratcheting of physician fees and the increasing burden of bureaucratic paperwork has caused many physicians to retire early and others to change their occupation.

The concept of using physician extenders is born of a wish to reduce consumer costs per provider as well as an attempt to increase the number of providers available for public care. The net result is confusing to the public as suppliers of care (hospitals, clinics, insurance companies, etc.) continue to use the same etymology to describe caregivers while changing the nature and training of those same providers.

Initially, physician extenders were conceived in the role of task completers, a designation previously used to describe medics, paramedics, and emergency medical technicians (EMT). These extenders could be trained to perform a specific procedure such as opening a chest cavity in surgery or suturing a wound. Soon the concept was extended to medical care delivery as medical assistants and nurses had done for decades. However, the industry was just evolving as physician shortages were becoming apparent, and the advanced-practice nurse was born. The advanced-practice nurse was a nurse who in general had completed an RN degree, a BS degree, had worked in an emergency room or intensive care unit for a minimum of one year, and had then gone back to school for advanced training and a Masters degree in nursing. Such nurses were especially qualified in areas of anesthesia, obstetrics, and routine medical exams.

While the training was fully appropriate for the responsibilities they were assuming, the industry and the politician/legislators wanted to be more creative and more efficient in producing physician extenders. The physician-assistant was born. These para-medically trained people held a bachelor's degree in any field and had subsequently two years of education in an accredited institution that trained physician assistants. What made these people unique was the breadth of knowledge of the totality of medicine and surgery which had to be absorbed in only two years. Furthermore, licensure was granted on the basis of completion of a two-year course and not the result of experience or demonstrated competence in medical practice.

When these people were asked to work under the direction of a physician, there was little problem as the physician directly supervised the care in question. However, soon physicians saw these providers as more than adjuncts to their practices, and physicians began to employ these extenders as additional physician providers to create a source of additional revenue. In some cases, they were introduced to patients as "doctor so-and-so," and not infrequently patients began to regard these extenders as physicians themselves. Ultimately the politician/legislators came to recognize physician extenders first as capable of functioning if they were within a fixed number of miles from a supervising physician and ultimately as being able to function under their own certificates of competence and license, independent of a physician.

The problems obviously arise when the physician extender obtains his/her continuing education from a supervising physician and concludes a diagnosis or initiates a treatment for which he/she is inadequately educated. This is compounded by the patient who expects immediate gratification and tells the physician extender what the problem is or what treatment the patient expects. In the past few years, I took care of a patient with a diagnosis of a brain cancer confirmed by two "doctors." Without belaboring the details of the case, the two "doctors" were physician extenders who had ordered thousands of dollars of laboratory tests, created untold anxiety and hardship on the patient, and came to an incorrect diagnosis any competent physician practicing under the standards of care in the United States would probably not have made. Another case involved a patient who asked her doctor to treat the lines under her nose. Her physician extender complied, ignoring the obvious diagnosis that the patient had wasting of the cheeks, and the result was a very unhappy patient who realized upon her return home that she looked "deformed." Additionally, I have seen several cases of laser burns of the skin, failure to diagnose the resulting scars, and failure to treat the resulting deformities. These procedures and their subsequent inadequate responses were in part the result of physicians delegating patient care to physician extenders.

The conclusion of this overview is not that the use of physician extenders per se is a poor concept, but rather that delegating and legitimizing skills which are not germane to the training and education of the physician extender imperils health care.

This article discusses issues of general interest and does not give any specific legal or business advice pertaining to any specific circumstances.  Before acting upon any of its information, you should obtain appropriate advice from a lawyer or other qualified professional.