To the Editor:

In Mr. Cawley's well-written article on workforce policy reform (“Physician assistants are an asset to health workforce policy reform,” published in July 2009), he makes a valid point: “PA graduates are selecting positions in the specialties because more positions are available … and because the specialties pay better.” However, a point that is rarely raised in these discussions is that PAs have never been able to self determine where they work. Our profession has enjoyed tremendous growth over its 41 years, but it has grown in ways that physicians, insurance companies (particularly large HMOs), and other stakeholders have decided it should. We'll never know what our profession would have looked like and what the landscape of primary care would have looked like if PAs could have chosen to maintain a strong sustained commitment to meeting the primary medical care needs of the nation.

The stewards of medical care in America, including insurance companies, large institutional health centers (such as the VA, NHSC), and physicians, have not done an adequate job of ensuring a sufficient number of front-line primary care providers to meet the needs of the nation. They have done a very good job of making ours the most expensive health care system in the world. As the workforce policy debate unfolds, I believe that PAs, through training and our historical mission, are uniquely positioned to help meet primary care needs; but we can't do that if we continue with the status quo of allowing PA job opportunities to be determined by other stakeholders in the medical community.

We need to be able to meet a community's primary care needs regardless of whether a physician or other health care organization has identified the need and advertised to hire a PA. We have to define a role that we and our physician partners are comfortable with and that allows PAs to work independently. This could translate into a minimum number of years of experience in primary care, a requirement for some additional primary care training, or a collaborative agreement with a primary care group. Whatever form the role takes, it needs to include a provision that allows PAs (like nurses, physical therapists, etc.) to bill for their services independently at rates that ensure an adequate number of PAs will seek these opportunities and offer cost savings to the health care system. Instead of continuing down the path of increased specialization with recently announced specialty boards, we should reaffirm our commitment to primary care and align ourselves with the American citizens, even if that means some bumps in the road with physician and insurance groups.

James Doody, MS, PA-C

Author's response: Mr. Doody makes an excellent point regarding the inability of the PA profession to determine its employment directions, and that is indeed an unfortunate handicap. It brings to mind a prescient quote from Ann Bliss, who wrote in 1975 that “immediately upon graduation, the physician's assistant (sic) is in considerable danger of being swallowed whole by the whale that is our present entrepreneurial, subspecialty medical practice system” (Sadler AF, Sadler BL, Bliss AA. The Physician's Assistant –Today and Tomorrow. 2nd ed. Cambridge, MA: Ballinger Press; 1975). That may have happened and we are indeed getting farther and farther from our primary care roots. A move to an independent practice stance could be justified on the basis of physician abdication of this field but likely would bring more resistance than merely “some bumps in the road.”

James F. Cawley, MPH, PA-C