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  • Writer's pictureRebekah Bernard

Physician assistant and PA-turned-physician discuss the state of the PA profession

When it comes to discussing the differences between physician assistants (PAs) and physicians, there is no one better to address the issues than someone who has trained and worked in both professions. Christin Giordano MD was a PA before deciding to return to medical school to become a physician. She has since completed residency training and a fellowship to become a nephrologist. We are also joined by Elizabeth Ennis, PA-C, a former classmate of Dr. Giordano, who is currently practicing in California. Together, we discuss the state of the PA profession, including the proposed name change from 'physician assistant' to 'physician associate' and independent practice for PAs.

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Rebekah Bernard MD 0:06

Welcome to 'Patients at Risk,' a discussion of the dangers that patients face when physicians are replaced with non physician practitioners. I'm your host, Dr. Rebekah Bernard. Before we start our program, I'd like to share a few words from our sponsor care cloud. Today I'm joined by two very special guests. First of all, we have Dr. Christin Giordano. She is a nephrologist in Tennessee who worked as a physician assistant before attending medical school. And we also have Elizabeth Ennis, a practicing physician assistant in California. Welcome both of you to the show.

Christin Giordano MD 1:32

Thank you.

Elizabeth Ennis PA 1:33

Thanks for having us.

Rebekah Bernard MD 1:34

Dr. Giordano, why don't we start out with you. Tell us a little bit about yourself and your background.

Christin Giordano MD 1:39

I was someone who thought I wanted to be a doctor when I was a little kid. I actually got into an eight year program at Brown and ultimately decided not to go to medical school, because I had heard from a lot of doctors that you can't have work life balance that I was looking for, and there was a lot of paperwork and you weren't going to be able to connect with patients. And while I was kind of having that crisis of who I was, my mom had gotten into an accident and a PA had actually taken care of her and did a lot of her postoperative care. And she said you should really look into this. And it seemed like a really good compromise where I'd be able to be taking care of patients and have the option to spend more time at home with my family and but also have a career. So I thought it would be a good kind of middle ground. I went to PA school where I actually met Elizabeth - we were in class together. And I learned a ton in two years. When I got out, I ended up taking a job in academia thinking, you know, I so much more to learn, I want to continue learning. And so I worked an academic position. And I you know, even while I was in PA school, I kind of wanted more from what we were learning. But once I was in the wards and taking care of patients, I was like, you know, this is actually really great. It's super exciting, taking care of people. And then while I was working, I actually had a mentor - a woman physician who showed me that you couldn't be the kind of doctor that I had envisioned from when I was you know, looking at my seven year old mind and my pediatrician, and she had a kid and was doing all the things and she inspired me to go back to medical school.

Rebekah Bernard MD 3:08

So, then you went back to medical school, and you decided to become a nephrologist. And tell us a little bit about what that training looked like.

Christin Giordano MD 3:17

Yeah, absolutely. So, we did four years. First two years at my school we did mostly didactic, meaning in the classroom learning, although we did some physical exam skills in the first and second year. The first year focused mostly on normal findings. And the second year focusing on abnormal findings as well as abnormal, pathology of things. And then our third and fourth year rotations, where we went through surgery, internal medicine, ICU, pediatrics, ob gyn, neurology, psych - I've probably forgotten something - emergency medicine. I don't want to leave anyone out. After medical school, I went on to internal medicine residency, which is three years. During that you're you're taking care of patients, but you have a graduated responsibility, meaning I took on more and more responsibility each year, under the guidance of a attending physician and went to lectures. I think we had something like eight to 10 hours of lecture a week in addition to our patient duties. I mean, it's present and we test along the way. And then I just completed a two year fellowship in nephrology on top of all that. So it was actually about 10 years from when I applied to medical school to when I finished my training to be a nephrologist. And I look back at the hours - I actually recorded and it was almost 16,000 hours between residency and fellowship so quite a lot of time in the hospital.

Rebekah Bernard MD 4:40

That is a lot Well Liz, tell us about your background and your journey to become a physician assistant.

Elizabeth Ennis PA 4:45

I started out as a respiratory therapist. I trained in Arizona and became a respiratory therapist providing respiratory care to patients in the hospital, to patients in nursing homes too. I also did home care, I did respiratory therapy in a sleep lab. I wanted to do more - I realized that, you know, I had kind of plateaued and reached a ceiling in my profession, and I had done it for 18 years. So I went back to school after my kids were grown, and I became a physician assistant.

Rebekah Bernard MD 5:16

And can you tell us a little bit about what your training was as a physician assistant and what kind of work you're doing now?

Elizabeth Ennis PA 5:22

I went to a two year program at University of Florida in Florida, which consisted of one year of didactic and one year of clinical training. The clinical training - we had to perform as interns and residents on our rotations. And it was 12 months of various rotations. We also had the opportunity to select additional rotations for like things that we were interested in and I chose ICU and cardiothoracic surgery were my electives. I'm kind of one of those adrenaline junkies. So that was, that was my thing. I thought it was a good experience. And when I got out of PA school, I also went into an academic setting, not similar to what Christin did down in South Florida, I went into a very, very large named institution, and I was expected to perform at the fellow level. And I went into Pulmonary and Critical Care. So it was a bit of a challenge. There was a steep learning curve with that. And then I decided that it just wasn't something that I wanted to stay with. It just it wasn't a great environment for a PA because at that time I had my attending tell me, 'you know, the only reason we hired a PA is because we're not allowed to hire physicians,' you know, it became a financial decision. And I didn't think that that was really, I didn't think it was fair to patients. And I didn't think it was fair to our team. So I moved on and went into urgent care where my attending I worked there for almost five years. My attending, he was board certified in internal medicine, emergency medicine, he had been a chiropractor before he went to med school. And he basically took me under his wing and we ran the urgent care like we ran an ER you know, we did labs, we did imaging, we sent patients directly from our urgent care to the cath lab. So I had a very different experience than what a lot of people get when they're fresh out of school. So I kind of did like an emergency medicine residency with this physician.

Rebekah Bernard MD 7:19

So interesting, what you just said about it really being - the situation that you were put in was very unfair to patients, but also to you. And unfortunately, this is the reality that we're seeing in corporate America, but also in academic centers. And perhaps some of it has to do with the residency hour restrictions in which they there's not as much reduced fee labor as there used to be. And so now, non physician practitioners are being put in this position where you're being paid less, but you're being expected to perform at a level that - how could you because you don't have that background and training. And I applaud you for saying no, I can't do that. But do you find that a lot of other PAs or nurse practitioners that you know, are going ahead and entering into that position and just trying to do the best that they can and learn it?

Elizabeth Ennis PA 8:11

Absolutely. I mean, what choice do they have?

Rebekah Bernard MD 8:14

Like you were lucky, because you were able to find another situation with someone who could mentor you and help you. But not everybody has that opportunity.

Elizabeth Ennis PA 8:22

There are always opportunities out there, if you're willing to go find them. But there's a lot of new grads that come out of PA school, similar to medical school residents, you know, they haven't worked before they got out of school, they don't have life experiences. You know, I was older, I've raised children, you know, I have a little bit more life experience to go on to be able to make those decisions and say, No, this isn't how it's going to be, this is how I'm going to do it. Because this is a better way to take care of people.

Rebekah Bernard MD 8:51

It's so interesting that you said that also because I've interviewed a physician anesthesiologist who was a nurse practitioner, and she said that she was told in her training, 'you're just as good as a physician, you can do everything the same.' And she said in the beginning, she kinda was like, Well, okay, but then, like you said, she had this life experience. And she had been a nurse for a long time. And she said, 'But wait a minute, this doesn't make sense.' And she was able to kind of stop, and she could because she had that insight. But she said a lot of her classmates that were young and just started out, they would hear that and they just believed it, because that's what they were told. And unfortunately, they may find out later on that it's not really true, but because the patient gets hurt or things don't go very well. Now, Christin, you've done both PA and physician training. So tell us a little bit about - first of all, just to clarify for our listeners, as Elizabeth mentioned, most PAs, first you go to four years of college, right, and most PAs have experience in the healthcare field - many of you do before you become PAs and I know you have to do a certain number of volunteer hours even if you haven't worked in the healthcare field. So then you go to four years of college and then most PA programs are two years master's programs, although there are some doctorate programs now. And it's estimated that the average pa gets about 2000 clinical hours of experience during their training. Does that sound about right?

Christin Giordano MD 10:12

Yeah, I would say 2-3000 would be a fair estimate of what we did in our second year.

Rebekah Bernard MD 10:17

Do you agree, Liz? Or are you think that might be a little inaccurate?

Elizabeth Ennis PA 10:21

I know, when we went to our clinical rotations, we were to adhere to the eight hour workweek. So for example, my first day in ob gyn was 24 hour call. I don't know what other schools do. But that's how our rotations went.

Rebekah Bernard MD 10:36

Right, it probably does certainly depend on the school. And so Christin, you had completed that training, and you kind of had this epiphany where you just felt like that wasn't enough training - that you needed to know more and wanted to know more. And you actually wrote about that for an article that I encourage everyone to take a look at. It's in Kevin MD, and we'll have a link in our show notes. It was actually shared over 9000 times and the title of the article was 'From PA to MD, an appreciation for physician education.' And you told a little bit about your story that you were just sharing with us that you wanted to be a physician, but you were a little disillusioned by some of the things that you heard. And I have to say that all physicians hear that when you're pre med and you tell somebody you want to be a doctor, then usually doctors that are already out say, 'Are you crazy? Like why would you want to do that?' So I can understand how you got disillusioned by that. And then you met a PA who was taking care of your mom and you were just so inspired and that made you want to go on to become a PA but then later on you went back and decided to go to medical school. So can you talk some of the things that you wrote about in your article - like how the clinical - not only the clinical, the science and then the clinical experience in medical school - was quite a bit different than from that in PA school. Can you talk a little bit about that?

Christin Giordano MD 11:52

One of the striking things when I started medical school compared to PA school was at least at our PA school - and I I there's probably some variation from school to school though PA schools are all accredited by the same organization and there's a standard. We had a huge focus on physical exam skills in PA school and taking a history. We actually went through Bates physical exam, and we - I don't know if you remember this trauma -we were quizzed on the person red, which was abnormal findings and it was pretty detailed and I felt pretty confident. We did history-taking with an attending in small groups, we actually saw real patients as first year students prior to going into second year. And so when I left PA school, I felt pretty confident in taking a good history and doing a physical exam in medical school, at least where I went. And I know that there's a difference amongst medical schools how they're doing this now - in the first few years, we had some focus on physical exam findings, but it was a weekly class and learning basic review systems and things like that, but it didn't actually have as much of a - like, I wasn't quizzed on a lot of the smaller details that we were in PA school. And I think compared to how I entered second year of PA school compared to or even finishing PA school compared to a 3rd year medical student in terms of my history and exam taking skills, I think those were at that juncture superior in terms of training. As we went through third year, I think there's a rapid catch up, where medical students quickly learn how to do those history and physical exam findings a little differently and are able to integrate the knowledge that they learned in their first two years. As far as complexity of topics, the depth of medical school is way more deep, we just have more time to do that. Because we're studying for two full years instead of just one year in our classrooms. Even though I had already done a lot of the surface work with PA school, I still spending many, many hours studying, I would go to class, let's say four ish hours a day. And then I'd be studying an additional six or so. And then on the weekends, I'd be studying six to 10 hours. We actually used to study together at night occasionally. But the amount of hours I'd say in PA school was not the same intensity as I did in med school. Even though I had already done PA school, I think that to me was the most kind of striking thing,

Rebekah Bernard MD 14:06

Right, like you would think that will maybe you can just even skip some of this stuff because you should have already theoretically you've already done it in PA school. But what you're saying is that maybe you had a little bit of an advantage going through PA school at least as far as history and physical. But as far as the depth of the maybe pathophysiology and things like that, that's where some of the differences were?

Christin Giordano MD 14:29

Some of the things that made life probably easier for me as a medical student, I already knew the language, right? I already knew a lot of the medications. We had been introduced to use this medication for this disease process. I knew some of the guidelines for cardiology, what you do if there's a heart attack, for example. So that stuff was easier to do and dealing with systems. I think PAs in particular are trained on how to come into a new system and figure out who to call quickly and how they help coordinate patient care really well. And that's not something we focus on in med school I don't think we get very good training early on. And that's something we learn as interns, is how do I coordinate patients going home and making sure that they have all the things they need. I feel like we got a lot of that in PA school. So we were thinking about that ahead of time. So we were more ready to enter practice, graduating PA school, compared to medical school, when you're when you know, you're going to have an intern year to learn some of those logistical things.

Rebekah Bernard MD 15:25

Liz, are you happy with your choice to be a PA? Do you ever - have you ever thought about going on to further education? Or do you feel like you have what you need to take care of patients in the role that you'd have now?

Elizabeth Ennis PA 15:37

I feel I'm okay, doing what I do. I've been doing this for 11 years, I've had a lot of really extensive training outside of PA school that is afforded me the ability to make more broad critical decisions. And I also I have a network of attending physicians that I work with on a regular basis, they're not supervising physicians. However, there's never a time like, if I have a patient that has, you know, an abnormal EKG, I can't run that by somebody who's an interventional cardiologist, because I built those networks. And I built those teams of my own like network of people that I want to make sure that I'm doing the best I can for every single patient I come across.

Rebekah Bernard MD 16:17

So right now you're in California, I think California, you still have a supervisory physician that you are assigned to or are you guys on the optimal team practice model there in California?

Elizabeth Ennis PA 16:28

We still have a designated physician that were assigned to, it's not something that has to be reported to the state. And we don't have to submit any paperwork saying that, yes, we're assigned, we have what they call collaborating physician agreements within our practice. Where I work for an organization that is an organization of 21 clinics that we have a multi specialty organization, we have endocrinology, we have GI people that we work with, we have cardiologists that we work with. So I have a network of people already in place. And it's just a matter of networking outside of our organization. If I need something different, like a podiatrist or, you know, a wound care specialists, I've built those work those working networks.

Rebekah Bernard MD 17:12

So are you working in a primary care capacity right now?

Elizabeth Ennis PA 17:15


Rebekah Bernard MD 17:16

And so would you say then that your patients are pretty much managed by you exclusively? And then you just go to a physician, if you have questions or concerns, or do you share patients with a physician?

Elizabeth Ennis PA 17:27

I do not share patients with a physician, my patients are assigned to me as their primary care provider. Occasionally, something will come up where I'll run something by my attending and be like, hey, this comes up. What do you think we should do with this? You know, things like that. But as far as like him having any kind of say, so over how I take care of these people? No, I'm pretty autonomous like that.

Rebekah Bernard MD 17:50

So let me ask you, I'm a family doctor. I'm a primary care physician and I did medical school and residency. Why shouldn't I have just gone to PA school and become a PA? Like, is there any reason that anybody should even go to medical school, I guess, is what I'm saying. Because it doesn't sound like you feel like in your, where you're working the way you're doing it, that maybe you have a lot of a need for a physician.

Elizabeth Ennis PA 18:13

I love my physicians, I would not work in a team environment that I wouldn't have a physician to be able to rely on. I like having that team approach. I like having the ability that, hey, if something comes up, you know, I'm not a trained physician. And I don't have ego to where it's like, oh, well, I'm the PA, I'm taking care of everything. It's not like that. I'm here to take care of what I can. And if there's something that's above my scope, I have no problem reaching out and have having somebody else helped me with that.

Rebekah Bernard MD 18:41

So what I hear you saying is you're you, you kind of know where what you know, what you should know and where you may need some extra help. And your training helps you to know where that is.

Elizabeth Ennis PA 18:51

I think my training helps me understand initially general things. And I've learned over the course of time since I've been practicing for 11 years, you know, more than just what generalists learn when they first get out of school. You know, it's it's similar to a residency I'm in like a long term residency for as long as I practice medicine, I'll be like the resident or fellow.

Rebekah Bernard MD 19:15

Lifelong learning. Christin, what do you think? Do you think learning on the job and formal residency training are the same? Or what are the nuances there in your opinion?

Christin Giordano MD 19:24

That's a really good question. I think we'll just experience is a little different too, because as she alludes to, she had a prior life, prior to going to PA school. And I think with that comes maturity that many new graduates might not have, and then that time as well to kind of know where you're, when you're out of your own depth. I mean, I've experienced her saying, like, 'Hey, I don't really know what what I should do, and I contacted my physician about this.' And that's unfortunately not the case for everyone. I think that residency is a very unique experience, in that you're fully immersed for a period of time three to seven years, depending on what you're doing. In that time, you're not just working, you're getting constant feedback from people on. I mean, people are seeing every single patient I saw for like the last five years or longer now was seen by an attending. And so I got that constant feedback of 'did you think about this,' 'make sure you're thinking about that.' And when you're learning on the job, you know, when I was working as a PA, you get some feedback. But there are patients that you are seeing on your own where you're attending doesn't see them. And so you, there's probably missed opportunities there where you could be learning and adding to your repertoire, but you don't get that opportunity. That's not the role of a PA isn't to become independent on their own, which is my goal, right, as a physician, so they're different goals, ultimately, and I don't think they're opposing at all. I think, ultimately, my hope, and I think she shares this hope, too, is that physicians and PAs will come together and kind of combat a lot of what we both have experienced in terms of corporate greed, putting PAs and nurse practitioners in unfair circumstances for them, as well as their patients. And for the physician too.

Rebekah Bernard MD 21:05

Well, you know, when I was writing the book, 'Patients at risk' with my co author, it was actually really hard to write about nurse practitioners and physician assistants kind of in the same breath, because they really are different professions, different training model. I've worked with both professions in my career. And personally, and I think a lot of physicians that I know, they really enjoy working with PAs because they know the model, and traditionally PAs have been really strong allies with physicians. And we've worked together so collaboratively just throughout, you know, for the last 45 years. But what's changing just here in the last couple of years, I think, has a lot to do with the increased independence of nurse practitioners. And the fact that it really has a negative impact on economic opportunities for PAs and I think many PAs may see it as unfair - and I kind of do - that they have this more standardized training, they have probably more clinical hours, and yet they're expected to work in more strict supervisory capacity than nurse practitioners who have independence and about half the states of the Union. What are your thoughts on that, Liz, as you think about how PAs - the profession and the leadership - is looking more towards this change towards optimal team practice and perhaps even independence? Do you think it has to do with the trend of NPs having more independence?

Elizabeth Ennis PA 22:30

I'd like to kind of clarify a little bit about optimal team practice. And, and there's a little bit of a misnomer that optimal team practice is geared towards full practice authority. And that's not entirely true. What we're looking to avoid is the administrative burden on the physicians as well as the PA is as far as like, Oh, you have to submit a supervising physician letter to the state of whatever state you're in. For example, in Florida, I'm licensed in Florida, so I can speak about Florida, as well as California, and they just recently passed a law that allows physicians to supervise 10 PAs instead of four, and the PA doesn't have to submit the supervisory form to the state anymore. That doesn't mean that they're not having a supervising physician, it means that we're able to work in a more broad scope of our practice without the constraints of the administrative paperwork stuff. It's just, it's, it makes me crazy. And I know it makes you guys crazy. So I think we're on the same team. And we want the same things, we want better patient care, and we want to remove those barriers to better patient care. And we've kind of been like behind the eight ball now, because of the the advancement of full practice authority with the nurse practitioners. It's like, now what's happening, our bean counters are getting in the way of providing adequate patient care, because they would rather hire a nurse practitioner who is, you know, independent, has their own malpractice doesn't require a supervising physician, they don't have to have any liability with the practice except their own. And that's a better cost driver for a bigger practice. And that's squeezing us out. What are we going to do? We have to do something.

Rebekah Bernard MD 24:09

Yeah, I definitely understand that. You know, when I worked in a federally qualified health center, I had several NPs and a PA under my supervision. And I thought it was kind of crazy that with a PA, I had to co sign every single note. But with the NP I didn't, but the PA had so much more training and experience than the NP, who was a new grad who really didn't have any experience at all. But it was just the law. And you're right, it didn't make any sense at all. Of course, as you know, here in Florida, we did get autonomous practice for nurse practitioners in primary care after a certain number of hours. And that also feels a little to me uncomfortable. Why would you allow one group autonomy and not another, but then I asked myself is the way around that to seek more independence as a group yourself> I guess that's easier to do than to try to take away independence from someone else. Is that kind of you think the thought process behind why the AAPA is endorsing more, not only the optimal team practice, but North Dakota became the first state in the Union to allow independent PA practice. So what are your thoughts about that?

Elizabeth Ennis PA 25:18

North Dakota was a state led independent practice act. Of course, it was supported by the AAPA, but it wasn't led by the AAPA. It's kind of like similar to the American Medical Association where, where they leave it to the state organizations to divvy up what they want per state. And then the AAPA, also known as AMA for you guys, kind of just oversees and just kind of travels along with it and says, 'Oh, yeah, that's a great idea,' or 'no, I don't know, we maybe we shouldn't do that.' I really think that for PAs to become more more readily used by the states and by physicians that we need to push for some sort of less administrative burden. I personally don't feel that PAs should practice independently. That was never what the design was intended for. I would not want to practice without an attending doctor to be able to rely on and I have 11 years experience. And I have really good training at really high high value places, you know, and absolutely, the doctors are the lead of the team. And that's the way it should be we work together. That's the way it's supposed to be because that's when you get the best patient care.

Rebekah Bernard MD 28:36

You know, I hear that so much from so many PAs, especially those with more experience. But I think some of the newer ones that are coming out may feel a little bit differently. What what are you hearing from colleagues or from newer graduates?

Elizabeth Ennis PA 28:48

I'm not hearing a whole lot because I don't have a lot of exposure to new graduates. I know from what I've read with the nurse practitioners that there's a big push from the very beginning to find that terminal doctoral degree. And I know my experience as a PA, that has never been our push to get that terminal doctoral degree to be able to be called doctor because we're not doctors. We were never trained to be doctors, we were trained to be adjunct to the physician. I don't like the word extender, because it sounds kind of demeaning. But really, if I've got a really good attending, and he teaches me everything he needs for me to know, to take care of his patients, I'm going to be an extension of him. And he's not going to be- or she- remain neutral. They're not going to be like, 'Oh, I can't believe that they did this.' And then, like who taught them how to do well, dude, I'm under your wing. You're the one who has trained me to do this. And I'm going to do as good if not better than what you teach me.

Rebekah Bernard MD 29:46

Let's talk for a few minutes about some of the new changes in terminology. We know that a few years ago, the AAPA came out with the idea of instead of calling physician assistant that name to use just the acronym PA and they had a campaign, 'just say PA!' And then now more recently, there has been a move towards endorsing the terminology Physician Associate. Christin, I want to start with you when you hear that name change, and that was voted by the AAPA House of Delegates. It's not official yet, there's going to have to be some things they have to go through to try to get that name change approved legislatively. But Christin, what are your thoughts when you hear about the name Physician Associate?

Christin Giordano MD 30:30

I think this is a complex issue. Because I agree with Elizabeth, there was a sense even back when we first graduated in 2010, that we were being edged out. And so there was like this already this pressure of what we need to do something different, to be hired because we're not being hired. In fact, employees were being hired routinely overpays in, when I was hired, I was being paid significantly less like 30% less than what the NP who was doing the exact same job I was doing was being paid and that was 10 years ago. And I think if I had to guess that has only widened. So I do understand this urgency to do something. And what that something is, is a complicated thing. And I really hope that physician leaders and PA leaders can get in the same room and really find a way to encourage corporations to hire PAs over NsS, I think that's the only thing that will turn the tide honestly, and will stop PAs from making decisions to try to do things to stand out or change things. I think the term Physician Associate can be confusing. I signed a contract actually says I'm Associate physician because that's what I'm not a partner yet. I'm Associate - that's confusing. And then to add to that we have assistant physicians who are medical students who've graduated, but physicians, but haven't entered residency. So that's confusing. We have graduate physicians who are the same thing. And they're also in some states, I think, in Arizona called associate physicians. So in all of this, patients are like what is going on? And I really think we need to find a way to make it very clear what everyone's role is on the team, the name change, I'm probably go with something completely different on in Physician Associate or even having something that's not physician in the title or something. Now clarify things and I am not privy to the other names that they consider. But my understanding was maybe the delegates, what they had voted voted for wasn't so representative, what people had desired. I'm not quite sure about all those details.

Rebekah Bernard MD 32:25

What do you think, Liz, about the title? When I look at it, the resolution passed 198 to 68. So it wasn't a unanimous vote. And of course, these are delegates. This certainly is not the PA profession at large. These are people who are involved in the political aspect. So you're right, it may not be representative. What do you think, Liz? Is the name change sound good to you? Or are you not in favor of it?

Elizabeth Ennis PA 32:48

I know we hired an independent marketing firm to be able to try and see what we could do to for rebranding, there were a select number of names that you know, physician, associate, keeping physician assistant, medical care practitioner, praxician, which that one got axed out right away, thank goodness. I'm like, 'praxician-what?' The branding company decided that medical care practitioner would be a good change. However, the House of Delegates when they voted, they decided to change it to Physician Associate, which was the second choice. Irregardless of whatever they call us, you know, assistant really doesn't fit what we do. I had a friend of mine, his mom asked me the other day, she's like, so do you wear a uniform when you're assisting the physician? And I'm like, 'No, I'm not a medical assistant. Like, I practice medicine. I prescribe medications. I diagnose and treat disease.' Basically, I tell patients, 'I'm a doctor on TV. I don't play doctor in real life,' you know, and they appreciate the humor. But also, you know, it's difficult for them to understand well, like, 'do you want to see the assistant? Or do you want to see one of the associate?' 'Well, I don't want to see the assistant, you know, they don't know what they're doing. I want to see an associate.' And patients don't know the difference between what Christin is called on her contract. You know, when she walks into a patient's room, she says, 'Hi, I'm Dr. Christin Giordano.; She doesn't say 'I'm a Physician Associate.' She doesn't say 'I'm an associate physician.' She says 'I'm Dr. So and So.' PAs are never gonna walk into a room - and they shouldn't - and say I'm Dr. So and so I don't think there's a confusion with that.

Rebekah Bernard MD 34:36

Christin, do you think there's confusion? Have you seen patients where they're not sure?

Christin Giordano MD 34:41

Less so for PAs then for NPs. I think the white coat in general is confusing patients. I've been mistaken for being a nurse more times than I can count. Despite my white coat.

Rebekah Bernard MD 34:52

I think that's common for most women in medicine.

Christin Giordano MD 34:55

So yeah, I think that there's just in general, patients don't understand what the roles pf people are on the team, regardless of what the names are, you know, the titles. I do think I refer to my equally trained - meaning physicians- as associates, I think of people who have not gone through the same training or level as not being associates, which is why I don't like the term assistant either. And like, I didn't even hear medical care practicioner, like coming up with something new was probably would have been better, I think, because it's less confusing. Ultimately, I think there should be a large patient education campaign around who is taking care of you on the medical team and explaining all the roles of those individuals, that patients aren't confused, without who's someone saying, 'I'm Dr. So and So' or 'I'm PA Ennis' or whatever, I you know, I have no idea. They don't know the difference. And I think ultimately, if you have a patient who has seen a primary care clinician, they often will assume that that person's a physician, whether or not Elizabeth could go in and say I'm a PA, I guarantee you there are some patients here that she's a doctor regardless.

Rebekah Bernard MD 36:03

Or they can see you and me and think that that 'well, when is the doctor coming in? I keep seeing that nurse.' Even though I have a big MD/DO badge.

Christin Giordano MD 36:16

They don't even know what that means. And that's on us right in our healthcare systems to educate patients on what each of those what the training is, and what the role of all those people are on the medical team.

Rebekah Bernard MD 36:27

I think as we've pointed out here, what's really important is that patients get the best quality of care possible, and that we try to be as truthful and transparent as we can be. And I want to thank both of you for coming to talk about this. And thank you for your hard work and taking care of patients. And of course, if you're listening and you'd like to learn more about these issues, I would encourage you to get our book it's called 'patients at risk the rise of the nurse practitioner and physician assistant and healthcare.' It's available at and at Barnes and Noble. If you're a physician and you'd like to learn more about getting involved with advocacy for patients and truth and transparency, then please join physicians for patient protection - our website physiciansforpatient Please listen and subscribe to our podcast and our YouTube channel. It's called Patients at Risk. Thank you so much, and we'll see you on the next podcast.

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