Communication is key to the MD-PA team

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My first interaction with physician assistants (PAs) occurred when I was 8 years old and was rounding with my father in the hospital. My father was a PA. Through him, I saw what PAs could accomplish: the ability to flex to all areas of medicine, the capacity to maximize responsibilities through strong mentorship, and the ability to positively affect patient care.
My father was a PA on the Alaska pipeline, worked on Indian reservations in North Dakota and South Dakota, assisted in cardiothoracic surgery in Alberta, and practiced inpatient and outpatient medicine in Arizona, Missouri, and Florida. The stories he told and the variety and flexibility of his career showed me what a productive MD-PA relationship could be.
I carried those memories with me through medical school, through residency, and eventually to my first leadership position as a hospitalist at East Carolina University (ECU). When we started the hospitalist program at ECU in 2002, one of the first things I insisted on was incorporating PAs into our program. Some physicians in our group didn't understand how PAs would work with us, but I knew. My father had taught me.
After 15 years of working with PAs and PA students at ECU, the Mayo Clinic, and Wake Forest University, I identified core building blocks that I believe are essential to developing a productive MD-PA relationship. First is the structure of the relationship. Some will espouse that MDs and PAs need to be “at the hip” working together. Others will say, just give PAs work to do and they can always call if they need you. I believe in neither approach. What I believe in is maximizing everyone's abilities, be they PAs or MDs.
My favorite day working with a new PA or PA student is the first day, for it is on the first day that I usually surprise them. “These are your patients today,” I say. “You are their primary provider, not me. See the patients, listen to them, examine them, review all their numbers and tests, and then come back and tell me what you want to do for your patient.” One hundred percent of the time, a new PA or student working in our program will make a mistake or miss something. That is exactly what I hope for. I want them to be wrong. But I also want us to talk through their thoughts and their decision-making process. I believe that when you push against your limits of knowledge, you learn and you get stronger. Because the patient's potassium is consistently low, what is the magnesium level? What did we do with the vancomycin dosing since the trough is low? Why is the patient's C-reactive protein (CRP) elevated? Why did we get a CRP in the first place? What is the big picture here? What is the timetable for the patient's discharge?
That structure will not be successful, though, without the second key part of the relationship, the support. Anyone in a new position is going to be unsure. My job is to reassure our new PAs and students that I am here for support and that our goals are aligned: we are here to help our patients the best way we can. I also relay that I am on the unit as well, and will be looking at our patients from a reasonable distance. I'm always accessible for any questions and encourage questions. But they are the ones who need to come up with a plan for the day. The art of the relationship is creating an environment where it is okay to fail.
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