The P.A. Problem: Who You See and What You Get

Recently, the New York Times published an article on excessive costs incurred by mid-level providers over-treating benign skin lesions. According to the piece, more than 15% of biopsies billed to Medicare in 2015 were done by unsupervised PA’s or Nurse Practitioners. Physicians across the country are becoming concerned mid-levels working independently without proper specialty training. Dr. Coldiron, a dermatologist, was interviewed by the Times and said, “What’s really going on is these practices…hire a bunch of P.A.’s and nurses and stick them out in clinics on their own. And they’re acting like doctors.”

They are working “like” doctors, yet do not have training equivalent to physicians. As a pediatrician, I have written about a missed diagnosis of an infant by an unscrupulous midlevel provider who embellished his pediatric expertise. This past summer, astute physician colleagues came across an independent physician assistant, Christie Kidd, PA-C, boldly referring to herself as a “dermatologist.” Her receptionist answers the phone by saying “Kidd Dermatology.”

The Doctors, a daytime talk show, accurately referred to Ms. Kidd on a May 7, 2015 segment as a “skin care specialist.” However, beauty magazines are not held to the same high standard; the dailymail.com, a publication in the UK, captioned a picture of “Dr. Christie Kidd”, as the “go-to MD practicing in Beverly Hills.”

The article shared how Ms. Kidd treats the Kardashian-Jenner family, “helping them to look luminous in their no-make-up selfies.”

While most of us cannot grasp the distress caused by not appearing luminous in no-makeup-selfies, this is significantly concerning for Kendall Jenner. At the tender age of 21, she inaccurately referred to Ms. Kidd as her “life-changing dermatologist.” Cosmopolitan continues the charade, publishing an article on the Jenner family “dermatologist.”

It astounds me how some medical professionals can contentedly live in the gray, south of brutal honesty, yet somewhere north of deceit. Until a few months ago, the Kidd Dermatology website erroneously listed her educational background as having graduated from the USC School of Medicine with honors and made no mention of her supervising physician. It was later modified to reflect she graduated from the Physician Assistant program at USC.

There are laws mandating physicians display diplomas and certifications prominently in the interest of transparency. According to Title 16, California Code of Regulations sections 1399.540 through 1399.546, a PA in “independent” practice is limited to the scope of his/her supervising physician by law. A board-certified plastic surgeon is supervising “skin specialist” Christie Kidd, PA-C, not a dermatologist. The website of the plastic surgeon states, “Trust only a Board-Certified Plastic Surgeon;” which in my opinion, seems astonishingly tongue-in-cheek. He may believe treating bullous pemphigoid disease is just another day in the life of plastic surgeons everywhere, but plastic surgery is a far cry from practicing dermatology and vice versa.

When asked about this, the Public Affairs Manager, Cassandra Hockenson, at the Medical Board of California responded “there is not a huge difference between plastic surgery and dermatology.” She suggested contacting the Physicians’ Assistant Board for the State of California instead. She kept repeating that the supervising plastic surgeon had no complaints against him. I learned two important lessons from contacting the Medical Board of California: 1) Without complaints, a physician can supervise midlevel providers in any specialty they choose, and 2) while required by law to supervise mid-level providers, the safety of patients is not a high priority for the Medical Board of California.

At a minimum, physicians complete four years of college, four of medical school, and between 3-7 years in residency. The years of education required for obtaining a PA degree are considerably fewer than that of an MD. For all intents and purposes, Christie Kidd, PA-C is running an independent dermatology practice directly under the nose of an apathetic California State Medical Board indifferent to regulations. PA’s can be fined and disciplined by their own board for misrepresentation, however, her “supervising” physician is, in fact, also out of compliance with the law.

While not all celebrities understand the difference in education between an MD or PA, mid-level providers and their supervising physicians should not be immune to the rules and regulations. Honesty, trust, and transparency are ideals essential to the medical profession. Physicians are held accountable for the health and safety of the patients we serve. Google Business modified the Kidd Dermatology listing from “Dermatologist” to “Medical Spa.” The unsinkable Christie Kidd struck a compromise, settling on the designation as a “skin care clinic.” Carpe Diem, Ms. Kidd, Carpe Diem.

Niran Al-Agba, MD is actually a physician. She practices in Washington state.

124 replies »

  1. Overall, this sounds like an angry and misinformed physician with a bruised ego. Never have I heard a PA refer to themselves as a Physician nor tout that their medical experience is equivalent to an MD. The MD and PA team that I work with have provided me with seamless care in a world renowned facility. I owe my life to the entire team, including the nurses and administrative staff. Perhaps you should have educated yourself about their education and training before writing this inaccurate and one-sided gibberish. Secondly, stop harassing a profession who’s intended purpose was to help extend access to patient care. Next time, direct your extinguisher to the fire (aka, PA Kidd) directly.

  2. Before knee surgury I was told repeatedly that my private areas would stay covered and underwear kept on during surgury. As a rape victim the thought of being exposed was mortifying!!!! There where stufents,sales person,and God knows who ever else they invite into what I believed was a safe secure environment exposed being knocked out. I woke up to the pa handing me my underwear and was told they where removed during surgury. She lied!!!! She flat out lied to me!!!! After I found out that hospitols where allowing class room full of stufents to come into surgury and all take a turn sticking their fingers in patients vaginas to do pelvic exam for practice with out their knowledge or permission! How many women do you know that would be ok getting finger fkd by a group of strangers while under antethsia? Thank God our government stopped this in mi!!!! Point is have you ever told a patient that would or did happen? Or that un licensed people where allowed in the or? Or that your surgury is on display for students to stare at you? I’m guessing NONE! this is why I do NOT trust dr or pa or rn! You all are not what best for the patient but what’s best for your own purposes. Rest assure I will NEVER NOT EVER GET KNOCKED OUT AGAIN!!!!!! ID RATHER DIE!

  3. The p.a.I see has me on 8 blood pressure pills a day.I have a sleep disorder and go 8 or 9 days without sleep.I have had a sleep study done and have chronic insomnia. She will not give me a sleep medication for this
    Also She is cutting me off some of my meds because it’s been 2 months since I’ve seen her can she do this?

  4. You took hours out of your day to paint a disparaging picture of PAs across the country because of a half-wit named Christie Kidd. What a great use of your time! Perhaps you should also consider researching and chronicling the unscrupulous history of your own peers. You would have an endless supply of content.

  5. I just found this article and had to log in just to comment. Your comment is incredibly uneducated, damaging, and inaccurate. No evidence is given. Instead, just subjective blanket insults are thrown towards NPs. I work with an incredible team made up of NPs, PAs, and physicians and we all show the utmost respect for one another. It is sad to know that there are medical professionals out there with such a biased, prejudiced view of their colleagues.

  6. Good discussion, Allan. I worry that with unusual diseases the correct diagnosis might not be made by the PA or the NP. Say someone with Hgb SC disease or someone with paroxysmal nocturnal hemoglobinuria or the superior mesentaric artery syndrome. But, we are all fallible people and unless you see these things once in awhile, we are all going to miss them, including the sharpest doc. Our longer training means that we might have a trace of memory for a few more rare things and even these traces help us look stuff up. Maybe with artificial intelligence, PAs and NPs can do a fine job in all these areas. My step son is a NP. He wishes sometimes he had gone into the PA route, as he believes there are more challenging jobs out there fo PAs. But he is thriving as a Kaiser cardiac case manager and making a good income. Kaiser is hiring more and more “techs”…they are cheaper, I guess.

  7. “ Why are you so bent on trying to put down the PA profession by pointing out what you perceive as the differences in training or in practice? “

    TPNA, where do you come off saying that? You keep assuming others are putting down PAs. You are touchy and defensive to anyone that questions anything about your profession. If you look again at my earlier comment I had two questions that were very neutral. “1) Are we appropriately utilizing our physician and physician extenders for the benefit of patients rather than profit or ego? 2) Not that long ago I believe the pool of physician extenders was relatively small…” and then in answer to a follow-up question I asked a question, (3)”In today’s world is the physician defining their role and if he is, is it based on the needs of the patient or the desires of the insurer?”

    These questions do not insinuate anything except to recognize the reality that we don’t know if the dog is wagging the tail or the tail is wagging the dog. Physician practices no longer have the independence they had in former days. Today’s physicians and their extenders frequently are treating code numbers rather than patients.

    ” it is incredibly difficult to get into a quality accredited PA program, many say it is harder than med school.”

    Many say? Many say the moon is made of green cheese when we all know it is made of blue cheese. I am not quite sure what you are trying to prove.

    What you call insulting is simply the truth. Horses and Zebras are very much “like” one another, but it is ill-advised to call them the same.

    “You brought up the situation of a sicker patient being sent to the PA vs the MD and that it should be the other way around. That is not up to the PA, it is up to the MD and the staff.”

    Suddenly the needs of the patient seem to melt away. The insurer, whether you realize it or not, substantially influences how physicians practice. That, in turn, influences how the practice decides who sees the patient.

    My questions neither favor the physician or the extender. They are questions of value and lead to the question of the best patient care and the ability of the patient to gain control over his own body. Nothing I am asking is meant to insult the PA or the physician. Do not assume that the person you are communicating with has no experience.

  8. Why are you so bent on trying to put down the PA profession by pointing out what you perceive as the differences in training or in practice? PAs are measured all the time, it is incredibly difficult to get into a quality accredited PA program, many say it is harder than med school. We take a difficult board exam, are required to do CMEs and repeat boards. Most importantly we are being placed in roles where we are doing exactly the same thing as Doctors. We are providing the exact same care in many areas of medicine so statements like “Horses are “like” Zebras, but they are far from being the same.” is very insulting. If you don’t want a defensive attitude you might want to stop using insulting questions and statements. PAs do not practice medicine based on the needs of insurance companies, I am one so I know. You brought up the situation of a sicker patient being sent to the PA vs the MD and that it should be the other way around. That is not up to the PA, it is up to the MD and the staff. If the MD tells people what he or she wants and defines the role they want their PA to take then we are a good team. I really hope if you are sick someday you get some quality care from a PA and your clear bias might begin to change.

  9. Ah thank you. I have not seen such a fuss before either, but it is interesting in that much in the way of dialogue may be generated. Beethoven is a worthy pursuit.

  10. AdamW, If I had expected individuals reading my work would bring my family members into the discussion, I might have spent less time putting together his Celebration of Life and more time updating my website.

    In two years of writing experience, no one has ever gone after me personally as two of the commenters did here.

    I picked one instance because it is a story and readers relate to stories. I have not cherry picked this one because she is a PA, you will see in other work I have written about NPs or other MDs when it seems appropriate. This was intended as a post about transparency and I discussed one rogue PA. This was not intended to insult the profession as a whole.

    Finally, as for updating my website being “truth in advertising”, my father passed away at the end of October, and to be honest (which I am to a fault), I have not decided what to do regarding the website. I am thinking on it, but it doesn’t feel right to erase my fathers existence after 47 years of practice in my hometown. Maybe it is just a notation mentioning he passed away in 2017 after founding our business partnership?

    You may feel I am intentionally being dishonest and that is your prerogative, in reality, I am grieving a huge loss of my father, business partner, colleague, friend, and mentor — all at the same time. While you may never read another thing I write because this piece angered you to such a great extent… you might like this one, https://www.kevinmd.com/blog/2017/10/physicians-deserve-mercy-silentnomore.html

    I believe it portrays that we are all doing the best we can in this field, whether MD, DO, PA, or NP. All the best to you in the future.

  11. For the record, dermatology is not a specialty that I enjoyed either. Being white myself, I have faced most prejudice in a situation like this where my name conjures up a preconceived notion of what someone of Arabic descent looks like. Some new patients show up in my office and can’t believe I look and talk “just like them” (their words not mine.) You should see their faces when they find out I am an Irish Catholic…
    Regardless, I agree with you that collaborative environment with respect amongst colleagues is the best choice and yes, many of us in rural areas are so darn busy, we would love to have an MD, NP, or PA join us; because our patient loads can really be overwhelming..

  12. I think your comments are very fair. Thank you for the constructive criticism on this piece. I have much to learn in the world of writing and am always looking to improve my skills. I do see your point about the flow. My intention was to introduce that the lines between physicians and mid-level providers are increasingly becoming blurred and then go on to describe a situation where one individual has taken misrepresentation to a higher level. I think all MDs, DOs, PAs, and NPs should be aware of this and help us all stay within our boundaries.

    As to the title change, ALL of the editors, whether at THCB, KevinMD (titles are ALWAYS altered), and even at my hometown newspaper where I write a monthly column, take liberties with titles and they are intended to grab readers attention.

    I had no intention of implying that all mid-levels are dishonest or incompetent, rather I wanted to open dialogue amongst all of us, as colleagues, to better define our roles and boundaries. Being open, honest, and transparent builds a patients’ trust and that is good for patients, all clinicians, and our healthcare system as a whole. Thank you for your feedback. I do appreciate it.

  13. Respectfully, most of us don’t. Do you really want to compare the PAs who daily labor to provide care to average Americans to those who cater to the KARDASHIANS? To be honest, I would never want to work in dermatology. Even dermatologists often cannot make a diagnosis, and treat empirically accordingly.

    I am sure that Dr. Al-Agba has faced unfair prejudices. Perhaps based on the fact she may not look like me. I have experienced white privilege on a daily basis. I know that I am treated differently than my African American colleagues, as well as other minorities, when their credentials are far superior to mine.

    Patients have preferred me to some MDs, because the MDs are “other”, even if they were born in the US. This is wrong, and I have told the patient as much.

    Never would I want to cheapen the sweat equity of MDs. But the fact remains that a minority of medical school graduates are going into primary care, and nature does abhore a vacuum.

    Is it better that patients receive no care rather than from a PA/NP?

    I am so grateful that I work in a collaborative practice with MDs who respect and value my efforts, and are far too busy to be threatened by me.

  14. I’m a former PA. I’ve been a physician for 12 years. PA school was very challenging. PA school is as competitive as med school so the IQ of a PA is very high. Any RN can go to NP school and most now do it online. RN’s love to tout how their RN exoerience should count fir something toward their NP. It’s apples and oranges. Until you’ve been both you can never understand how you just can’t know what you don’t know. The eyes cannot see what the mind does not know. This article is about a PA gone rogue. More often this is a story about an NP. In general PA’s are a stronger bunch and much less likely to advocate for independence. But it has been happening in some states. I support the PA profession as long as it stays on our team. NP’s will meet their maker when they start getting sued for their stupidity. As physicians there is a new nationwide movement to not train NP’s. Guess they’ll be doing their rotations online as well.

  15. Being neither MD, PA, NP, RN or anything else with initials, I don’t have a dog in this hunt. But as a reader and interested inhabitant of the peanut gallery, perhaps I can suggest a bit of clarification. Perhaps Dr. Al-Agba could ask the editor to restore her original title, as the current title appears to be a point of contention with the mid-level practitioners.

    Also, the first paragraph, about mid-levels over-treating benign skin lesions, does not logically lead to the content of the remainder of the article, which Dr. Al-Agba states is about transparency and which discusses the case of a single PA failing to clarify that she is not a physician. If this article is truly about transparency and correctly identifying one’s professional education and credentials, then the first paragraph is out of place – and would be more appropriate in an article discussing why mid-levels might be overtreating certain conditions. As it is, conflating the first paragraph with the content of the remainder of the article and adding in the current title (which I can accept was an editorial decision rather than Dr. Al-Agba’s intended meaning) leaves an impression that mid-levels are dishonest and incompetent, so I, as an unbiased spectator, can see why the mid-levels here might be perturbed.

  16. As a PA, this is concerning. It seems like Christie Kidd was intentionally trying to mislead the public as to her degree and qualifications. I always correct my patients when they refer to me a Dr. Anon, and explain that I am a PA and work in collaboration with physicians.

    What are your thoughts on DNPs who open their own clinics and refer to themselves are Dr. SoandSo?

    I see this quite frequently as I live in a rural state that grants NPs independent practice, even as new graduates. Unfortunately when I express my concern about this to NPs, the response is usually that nurse has a doctorate and has a right to themselves doctor. Although, from what I understand, the DNP when compared to ARNP confers no increase in clinical knowledge, rather more education on nursing theory.

  17. There is a lot of misinformation in this comment. Lets break it down:
    1. “They only need a BA in every subject, ex: art history”. True, you can have a 4 year degree in anything. However, no matter what degree you obtain, there multiple prerequisite course requirements in biology, inorganic chemistry, organic chemistry, statistics, and upper-level science courses ranging from microbiology to embryology. Here is an example: https://medicine.uiowa.edu/pa/education/prospective-students/course-requirements . Exact requirements may differ between schools, but overall you must have taken courses in the hard sciences regardless of your undergraduate degree.

    2. “It used to be they didn’t need any clinical before they began practice. Now at least clinical hours are required” . Like djwatt21 commented, the PA profession was founded during a period of primary care physician shortage so that medics, who had received considerable medical training during their military service, could work alongside physicians to improve access to care. Things have changed and not all PAs and PA students have a military background, however patient care experience is STILL a requirement. And while there are minimum amount of hours, usually the amount of experience of accepted applicants if much higher.

    3. “On the other hand even a nurse who graduated and goes straight to NP school has 2 years prerequisite, 2 to 4 years nursing school and then 2 to 3 years NP school.” Lets do some math. Using the information above it looks like NPs have potentially 6-9 years of training. Two years of prerequisites is not always a necessity, there are nursing programs that accept students straight out of highschool, so that is not a constant. This brings us down to 4-7 years. Two to 4 years of nursing school is comparable to the required 4 year degree of all PA programs. Now, it’s 2-3 years for NP programs compared to the minimum 2 years for PA programs (many programs are increasing the length of programs to 28 months to allow to more clinical experience). NP training is online and this allows the student to work, would this be considered full time? Contrast this to PA education which is 8 hours per day, 5 days per week for the majority of the program (maybe 1-2 week breaks during the first year). All the programs I know of state on their websites that it is not feasible for the student to work during their program due the intensive time requirement. I should also note that there are PA residencies for those interested in specific fields of medicine, e.g. emergency medicine, psychology etc.

    4. “Clinical time is required in all nursing rotations”. This point must be a joke. NP programs generally involve 500-750 hours of clinical rotation. Minimum standard for PA education is 2000 hours of clinical rotation.

    5. “In addition most nurses work at bedside while pursuing advanced degrees”. This is true, and I work with some fantastic NPs that were ICU nurses for 7+ years before beginning NP programs. However with the proliferation of NP programs, newly graduated nurses are starting programs with no nursing experience, and from what I have experienced working with some of these nurses is that they have no interest in patient care as a nurse, only in getting there NP degree as fast as possible. I know anecdotal evidence is some of the weakest out there but this is my experience, take it with a grain of salt.

    6. “NPs treat the whole patient, PAs are just what the title says an assistant to a physician or physician extender.”. I don’t know if the commenter has ever met a PA or is sure of our function. My training emphasized treating the whole patient, not just disease. In fact, I often read that “the nursing model treats the whole patient, while the medical model just focuses on the pathophysiology of disease”. My program shared a majority of its coursework with the medical students, and we were all taught to treat the whole patient. In my current position, I certainly am not just an assistant to a physician; I carry my own patient load, write my own notes, do my own admissions. I have to admit, having the word ‘assistant’ confuses a fair number of people, apparently even some in the healthcare world.

    7 “An NP is an independent practitioner with some states requiring physician oversight. Please do not lump us together the education and practice are not the same”. Just because a state law grants NPs independence does not mean that you SHOULD have independence. Especially for new graduates. There should always be some degree of collaboration with physicians because, as much as we can argue about whose education is more rigorous, NP and PA education does not compare to that of a physician. PA and NP are two different routes to the same kind of position.

    I know this is a long comment, but I will not apologize for it. Misinformation like that of the original commenter only works to pit NPs and PAs against each other.

  18. As a physician, the insecurity by PA’s here is astonishing. Dr. Al-Agba was only stating that it’s not correct to misrepresent yourself and to not reveal to patients that you are trained much differently from physicians. It was well-written and her critique of the PA in question was restrained and fair also.

  19. I’m sorry you feel that way. “Vitriol” is a very strong word to use when I’m simply asking for you to advocate supporting an open dialogue, and understand how your article title, while not your own, may shut that down. Again, you could not have allowed the title change if you also disagree with it.

    As for the subject matter – we should all be very clear about our licensing and skill set. This can be complicated in actual daily practice but it doesn’t change our responsibility to be clear about who we are and correct patients when they are confused about credentials. I fully support that level of transparency and make effort to do so in my daily practice as well.

    Furthermore, while I work with NPs and feel very strongly about them as colleagues, NPs are very clearly forging ahead in an effort for continued autonomy of practice. Many states already allow them to function independently, as well as the VA, and essentially all NP programs are now becoming doctoral level degrees. On the other hand, our professional organization, the AAPA, just reaffirmed our dedication to team based practice with the endorsement of “Optimal Team Practice” language. This was in response to initial planning around “full practice authority” (essentially what NPs have in many states). Rather than forging down that path, PAs embraced the physician lead healthcare team as we always have. So I ask you – given these facts, who among us is mostly likely to misrepresent their training, intentionally or otherwise?

    Finally, while it isn’t the same example, in what way is a physician who overbills for unnecessary procedures any better or worse than the PA referenced in this article? Consider the various stories of physicians committing Medicare fraud as a result of such practices.

    Whatever the case, we have a responsibility to our patients. Any example that undermines the trust of these folks in a notable way should be identified and examined in an effort to do better.

  20. So, where is Ms. Kidd? No comments? Has she changed her misrepresentation? She must know the shock wave she has sent through her profession…does California have a law against false advertising?

  21. Okay let’s reel that one in a little bit. Don’t forget the history of the PA profession is one of battlefield medics being converted to civilian medical providers. Yes our field has evolved tremendously since that time, but there is still an enormous number of second career folks, many from the medical field. Regardless, admission to PA school, subsequent training, clinical rotations, and certification are extremely rigorous. Please do not insinuate otherwise. This is not a competition among license types. With respect to education and training, the typical PA program, while similar in length to NP training programs, averages 1000 classroom hours and 2000 or more hours in a clinical setting. The average NP program, comparatively, requires about 500 classroom hours and between 500 and 700 clinical hours. Furthermore, NPs have no ongoing certification maintenance requirements outside of CMEs (75-150 hours) and clinical hours (1000 in their field of practice) per 5 years. PAs require 100 hours CME every 2 years and must recertify thru examination every 10 years (this was recently revised from 6 years to be more consistent with our physician colleagues). Again, this is not about the measuring stick here, but there are very significant differences in the extent of our training programs such that a statement like “I do not believe PA’s and NP’s should be referred to in the same breath” doesn’t hold water. Regardless, I work side by side with awesome NPs in my practice, and ones that I’m sure wouldn’t make these erroneous accusations about PAs and our training.

  22. I deeply admire your patience with all of this. During several years of “Blogging,” I have never seen such a fuss. As I write, I usually listen to some of my favorite composers, mostly classical. The level of creative purity usually leaves these issues in the dust. Tonight, its the Choral Fantasy by Beethoven. The search for truth, left unattended, is no longer an alternative when the choral ending occurs.

  23. My fnp practicum is 1800 hours in addition to my 26 years of practice in peds peds ICU, nnicu, adult ICU, cicu, rapid response, nurse supervisor, dialysis, EP lab, home health and ltac!

  24. What you do and what a physician does are NOT identical. Physicians have training in many areas, they do rotations in all aspects of health care then pick a specialty and do a fellowship. That knowledge cannot be gained during a PA program. As a bedside nurse and NP student I see the knowledge physicians have. Many times I get a call at 2am from a physician who has been up all night trying to figure out why a patient is not responding to care as they should. When they call they may have found an ebp article and suggest a different treatment. Sometimes I have heard of a treatment in my studies and I run by the doc. Sometimes we try any idea. I believe most physicians have confidence in RNs.

  25. Respect does go both ways. I respect the knowledge if all physicians I work with. Hell, I helped raise many of them from baby docs to attendings. Those physicians also respect me and my knowledge. They have said they will be sorry to see me leave bedside but look forward to collaborating with me. I have had a long bedside RN career in many areas of nursing, I have physicians already asking if I want to partner with them.

  26. NPs in many states and federal facilities do not need physician to practice. Even in my state of South Carolina, I do not need physisn on site just available within 45 miles

  27. I believe some think it is an attack article due to the fact that the first paragraph talks of unsupervised PAs and NPs

  28. I personally do not know any NPs who do not correct pts when they are referred to as “doc”. Even DNPs tell pts their doctorate us in nursing not medicine. As I’ve said previously, if I wanted to be a physician I would have gone to medical school

  29. I must reiterate, an NP is not a physician helper but is an independent practitioner. A PA is a physician assistant.

  30. I am truly sorry you have stopped precepting NP students! NPs are usually very open to learning and criticism. We are the only advanced practice who have to secure our own preceptor. I hope you will agree with me that most NPs do not want to be physicians, if we did we would go to med school. Most NOs take a cut in pay when they leave the bedside and many still pick up shifts at bedside to make up for that cut in pay. We are paid less but able to spend a little more time with patients, this is because physicians are forced to see a patient every 10 to 15 minutes. NPs collaborate with physians for the best care if the patient.

  31. Aside from everything else discussed here, taking the medical advice of a Kardashian/Jenner is a recipe for disaster.

  32. I do not believe PA’s and NP’s should be referred to in the same breath. I agree PAs must have doctor oversight at all times, unless employed by a federal program. They only need a BA in any subject, ex: art history. Then they attend PA school. It used to be they didn’t need any clinical before they began practice. Now at least clinical hours are required. On the other hand even a nurse who graduated and goes straight to NP school has 2 years prerequisite, 2 to 4 years nursing school and then 2 to 3 years NP school. Clinical time is required in all nursing rotations. In addition most nurses work at bedside while pursuing advanced degrees. I, for example, had 2 years pre reqs, 3 years for my associate in nursing. Practiced for 15 years, then 3 years for my BSN. Still practicing , 2 more years for my MSN and now in an FNP program. I have been practicing at bedside for 26 years. You cannot compare an NP to a PA. NPs treat the whole patient, PAs are just what the title says an assistant to a physician or physician extender. An NP is an independent practitioner with some states requiring physician oversight. Please do not lump us together the education and practice are not the same;

  33. MD graduates are measured all the time and their measurements frequently start before college. Right or wrong our nation took a path to provide the best education and assumedly provide the best care. That is why the MD supervises the PA and not the opposite. I’m not saying this is the best way to manage things, but it is the gold standard today. Therefore it is up to you to prove the scenario you prefer.

    As far as grading we could have PA’s take the same test FMG’s take when they enter the country and then for generalists they could take the Internal Medicine Boards and the subspecialty boards if they are specializing. Again I am not saying this is the best way to manage things, but it is a way.

    “If you understood”

    What makes you so sure I don’t understand?

    “anyone should be defining their role as a provider of medicine based on the desires of the insurer?”

    Unfortunately, that is exactly what is happening today. He who pays the piper calls the tune and the patient isn’t the one paying.

    ” PAs are trained like Physicians”

    Horses are “like” Zebras, but they are far from being the same.

    “never in a million years care for someone based on the needs of an insurance company.”

    Look again.

    I am not insinuating anything. My questions in my first entry were left open and can be looked at from any direction. You are very defensive so you are looking at the situation only from the side of protecting the PA, not the patient. A defensive attitude doesn’t help anyone reach an understanding of the issues involved.

  34. How exactly would you measure the quality of PA graduates and for what reason? If we did so then why would we not also measure the quality of MD graduates? If you understood the history of PAs and their current educational standards and the accreditation process then I don’t think any measure of the quality is needed.

    And are you serious that anyone should be defining their role as a provider of medicine based on the desires of the insurer? Who would ever even ask that statement? PAs are trained like Physicians and take the same Hippocratic Oath and would never in a million years care for someone based on the needs of an insurance company.

    I am confused by these questions and it seems you are trying to insinuate PAs are not being trained to practice medicine at all and are just around to pad the numbers by seeing more patients.

  35. ” I don’t think we can make generalized statements about the quality of current PA and NP graduates ”

    Are you saying that such assessments should not be considered?

    “I feel the appropriate way to utilize PAs is for Physicians to take the lead in defining their role”

    In today’s world is the physician defining their role and if he is, is it based on the needs of the patient or the desires of the insurer?

  36. see my comment above. I don’t think we can make generalized statements about the quality of current PA and NP graduates but certainly the more we have the greater the variety. In essence, I feel the appropriate way to utilize PAs is for Physicians to take the lead in defining their role which may be unique to the Physician or environment they work.

  37. Thanks, Niran, I was hoping some from the PA / NA community would comment on those questions. We can’t simply talk about blurred lines rather we need to talk about what suddenly precipitated these blurred lines and whether or not the patient should be provided choice over their own bodies.

    Right now it seems too many responders are in a defensive position rather open to debate on policy considerations.

  38. Can you tell me how I was supposed to know that her father was deceased? On her clinic website, his name and biography is still prominently displayed as one of two practicing physician’s, the other is the author. She is touting truth in advertising, but doesn’t seem to practice what she preaches.

    My intent was to show that the senior Dr. Al-Agba, as a foreign trained doctor, was likely a competent clinician…just like a PA, can be a good clinician, yet there is a vocal group of people that exclaim that US trained physicians are superior. Just like, there are a vocal few (Dr. Al-Agba being one of them along with the dermatologist that she cited) that use their pedestal to denigrate PA’s…without evidence or apparent reason.

    YES, PA’ s should make sure that their patients know that they are seeing a PA, just like they should be informed that they are seeing a MD, DO, NP, RN, RT, PsyD, etc. Why pick one instance, from a day time talk show, no-less, to target PA’s?

  39. Great questions Allan, as usual. I don’t have the answers but wanted to open the discussion. Thank you.

  40. What you have written is excellent commentary. We are having an important conversation about collaboration and better defining roles on the healthcare team. Thank you. In the media, sometimes there needs to be a little controversy to get the ball rolling. While you may feel this piece was demeaning, it was truly not intended that way.

  41. Nobody disagrees with the perils of misrepresentation. Interestingly this article has touched on a different issue, the role of midlevels or perhaps just PAs in healthcare. The PA training is a much abbreviated mirror version of med school. In practice PAs are being given virtually identical roles and responsibilities. I have heard some good Physicians say that after about 5 years of practicing, a good PA who studies the evidence and is mentored by Physicians can be every bit as knowledgeable as any Physician, especially given our rapidly changing medical environment. I also believe that there are many other important factors other than training that distinguish quality providers, such as emotional intelligence. This article was demeaning toward the PA role in healthcare and I am sorry the Physicians don’t seem to see that but I do have a favor to ask. As the number of PAs is growing rapidly and lines of roles and responsibilities are being blurred, it is not only important for PAs to represent themselves correctly but I also ask that Physicians be more proactive in defining the PA role. Each Physician I have worked with over the years has a unique style and some practice very differently. I have always taken on the role of being an extension of their practice style and done so with very little guidance from them. Every area of medicine and every Physician is going to be somewhat unique in how they see the role of PAs and I think Physicians are in the best position to be leaders in defining the role of the PA. If you want to be involved in all the complicated patients then you must say so, if you want to only be doing new admissions and regulatory visits in nursing facilities and have the PA do most of the care during their stay then you must define that as directly and clearly as you can. Playing to each others strengths for example makes a team of a Physician and a PA more effective at delivering quality care. If you do this well then the collaboration can dramatically improve the quality of care patients receive, if you demean the role as this article did then the collaboration suffers.

  42. To have professionals misrepresent who they are and professional policing organizations lack understanding erodes the trust of the public and makes it harder for anyone who treats patients. This article pointed to a state medical board spokesperson who clearly does not recognize differences in specialties, a physician supervising a PA in a specialty in which he himself is not boarded, a PA misrepresenting herself, and layers of the press, misunderstanding the training of a myriad of professionals. If all professionals do not insist on the honesty and transparency called for in this article, we ALL… our boards, physicians, PA and the press will continue to erode the public trust.

  43. This has been going on for years, and if anything became a national problem during the Obama years. Both Democrats and Republicans are responsible.

    We can pin a lot of things on Trump but this isn’t one of them.

  44. The lines in healthcare have been intentionally blurred by all parties involved. The HMO blurred the lines using the term “healthcare provider”. Is a healthcare provider a doctor, a nurse, a PA or an NP? The use of physician extenders is and was an attempt to save money. A hospital might use non-M.D.’s for the same reason and a physician might use them to increase his income by increasing the number of patients being seen. Somewhere in that blurred line trouble is brewing. It is not uncommon for the sicker patients to be given appointments with the physician extender because the physician is booked up in advance seeing healthier patients. No affront to the physician extenders or the physician, but shouldn’t it be the other way around?

    How many times have we all heard that physicians make too many mistakes and aren’t trained well enough? I used to hear that quite a bit. If physicians aren’t trained enough with all their hours of training then what can be said about a PA or an NP? The questions I have with regard to this issue are 1) Are we appropriately utilizing our physician and physician extenders for the benefit of patients rather than profit or ego? 2) Not that long ago I believe the pool of physician extenders was relatively small and was comprised of individuals that I think were very suited for the job. We are now pushing programs to graduate more and more PA / NPs. Is that pool as good and dedicated as the earlier pool?

  45. This is an example of the Republican plan to let market forces bring down the cost of medical care. Don’t need no stinkin regulations.

    I will say the PA I go to is great at diagnosis and treatment. I have a lot of experience with bad docs to compare him to.

  46. There is a reason the United States is considered to be the country with the best medicine in the world. That is not to imply that other industrialized nations do not provide excellent medical care, they do. Yet, plenty of their physicians desire to come to the U.S. to practice medicine, despite the prolonged path they must complete to practice in America. The U.S. has always been the best, no doubt partly due to stringent educational and practice standards. Yes, for hundreds of years medicine was more of an apprenticeship than a formal didactic education. But advances in medicine and the progression of a civilized society DEMANDED improvement and standardization of the educational process. And you think it is a good idea to go backwards? The first open-heart surgery, the eradication of polio due to the development of the polio vaccine, the treatment of certain congenital disorders, antiseptic technique, the development of artificial skin, the first test tube baby, etc.; all of these accomplishments didn’t happen by osmosis. Physicians made these events happen to the betterment of mankind. It is offensive to me for you to say that the educational process of becoming a physician is unnecessary. One’s understanding of the pathophysiology of disease and pharmacological management must be solid. Do not minimize the significance of this contribution to good clinical medicine because you believe it to be overrated.

  47. In my opinion, the gist of the article is a failure to be truthful in advertising one’s title, education and practice. Perhaps many of the respondents may have taken offense by Dr. Al-Agba’s delivery, but do not allow that to cloud the issue. To intentionally misrepresent one’s self as something he/she is not, especially in healthcare, seems especially egregious to me. Patients can hardly be expected to understand the myriad of titles that come before and after a practitioner’s name. It is confusing, even to those of us who work within the medical industry. But blatant lying is despicable. Ms. Kidd intentionally misrepresented herself and it is wrong. And if one admits that what she has done is wrong, then do not justify or minimize her behavior.

    After 22 years of practice in Emergency Medicine, I made the conscious decision two years ago to cease supervising PA’s and NP’s. I have taught, worked with and supervised these providers during my entire career. There was a time if a patient referred to a PA as “Doctor” they were immediately corrected by that PA. There was a pride about who they were and what they represented. Their role within the health care team was defined and complementary with physicians. They were receptive to my leadership and there was no sense of competition, just teamwork. There is now a blurring of the lines and they are no longer correcting patients. They disregard or become offended by my leadership, which is the same style I have used for 22 years. I’ve traveled extensively in and out of the U.S. and worked at various hospitals in different settings. This trend is pervasive. And unnerving. I will not risk my license for someone who has no interest in respecting my role within the physician-led team. The reality is that the education, training and practice of physicians, physician assistants and nurse practitioners are distinct and different. Admittedly, there is overlap of each practice, how can there not be? However, that does not change the fact that each role is unique and important in its own right. Why would one want to perpetrate a fraud? There is no need for anyone to fill another’s shoes when the shoes don’t fit. Can’t fill a physician gap with a non-physician. Be proud and represent one’s own field with dignity. Ms. Kidd seems almost ashamed–in action, not words. If there is anything disheartening about this article, it is her silent omission of her true title. Be angry about that.

  48. Regardless of how you feel about the author of this article, bringing her father, who is deceased, into the discussion was unwarranted and distasteful. Surely you could have made your point in a more eloquent and sophisticated way, don’t you think?

  49. Ohh..My. I am at a loss for words. The title of YOUR article, is “The PA Problem: Who You See Is What You Get.” Typically the author titles their work! Who else would have titled it?

    Secondly, I would again urge you to do some self reflection. My posts have had no negative racial or anti immigrant connotation and for you to imply otherwise is more telling of you. Your article was disparaging of my profession and now you are trying to imply that I provided negative commentary on foreigners! Quite the opposite. Your article and your responses to me and others reeks of narcissism.

    How you can behave this way and be a pediatrician is appalling! I am done…

  50. This is such a timely well written article! In this day, it is so important to shed light when an individual or group fails to comply with truth in advertising and proper supervision in the medical setting. Mid levels I know agree with this sentiment wholeheartedly. It’s sad when there are some who take offense when no offense was intended however. So I personally thank you. More importantly patients thank you!

  51. I dont understand why so many mid level providers are upset by this post. Everyone wants to claim to be “equal to a physician” (and many on this comment thread proudly state they are “better than”) but no one wants to put in the work. Medical school = physician. Shorter track= physician helper. Does being a helper mean you do not provide quality care? Of course not. Lets just be transparent with the titles. Its sounds like an ego issue. Many PAs and NPs are seeing their role in healthcare as equivalent to a physician since they carry similar duties (with less liability) and appear offended that their lower education is highlighted as being inferior to physician training.

  52. Dr. Nelson. Frankly, I am shocked at the outcry. Two PAs commenting researched my background and insulted my deceased dad for being a foreign medical graduate. They don’t realize he had 15 years post secondary education to go out into practice and passed pediatric and endocrine boards. I do think years of education are important, most of all, being transparent about our years of education is vital. I don’t see what the controversy above in comments is all about.

  53. Thank you for making it clear this is very personal for you and no matter what, I cannot assuage your vitriol. Further discourse makes no sense.

  54. As a physician in California who has supervised NPs and PAs, this topic is truly an important one. Patients should have the right to know who is treating them and clearly understand the differences in their health care provider. Midlevels are not equal to physicians!! I have seen too many mistakes and am thankful that I was there to supervise. If you really care about patient safety then you would know what I mean.

  55. I’m so glad you finally see this is not a piece insulting the physician assistant profession and instead, about transparency.

  56. Not my words: neither the title nor the “actually” in the tagline. Sorry to disappoint you there. I did not question the competency of thousands of clinicians. You seem focused on making this about denigrating large groups: related to ethnic or foreign background. I do not support that sort of discriminatory rhetoric. Discussing misrepresentation of a clinician in no way opens up your negative commentary on foreigners or immigrants.

  57. It’s also worth stating that you really don’t get to abdicate responsibility for the ultimate title of this article. If you agree the title is unnecessarily inflammatory of the PA profession then you should be as frustrated or upset as many of my colleagues here. If open dialogue around transparency is important, then you must consider how the tone of the title and article may negatively impact that possibility.

  58. For someone who writes carefully and thoughtfully, did you expect such an outcry? It all does beg the question as to why I really valued my 10 years of medical education (2 years extra during medical school for M.S. in physiology)? It might be worth a separate discussion in the future. Paul

  59. All well and good. However, the content of your article and the subsequent commentary from others here substantiates my point. Whatever the case, we should hold all our clinical peers to the same standard. The individual case you call out is exactly that – one example. Let us not presume to somehow extrapolate this information to reflect a larger statement about PAs and PA practice. I’m lucky to work in a truly team based practice setting so perhaps some of the attitudes conveyed here are simply more foreign to me.

  60. So as long as you’re nice and sweet, it doesn’t matter if you misdiagnose and harm the patient. Ok, got it! Next time, my car’s fuel pump goes out, ill try to look for the nice guy instead of a mechanic.

  61. If misrepresentation is what it was about then myself and every decent PA has zero disagreement. What you are clearly missing is the very demeaning tone. It is the inflammatory statements in this article that make this a PA vs MD discussion and not about misrepresentation. I am a PA who greatly respects the MDs I work with and who feels incredibly grateful for their mentorship. I also feel very respected by them and know what it is like to work in a collaborative team environment. I also have a PHD in Biochemistry and know and value the importance of training and education. So I am not bitter nor do I feel undervalued as a PA but referring to PAs as “playing doctor” and inferring that without close MD oversight we are not as good or competent as MDs is not the reality that I work in every day. I can out diagnose and give flat out better care than many MDs I have worked with but that doesn’t make me go around claiming I had more training and education by passing myself off as an MD. My claim is that I am a good PA that can out diagnose and give better care because I learned how over eight years of practicing and studying and caring. Skills like being present with a patient and really listening to them have nothing to do with a PAs vs an MDs training and yet I believe make someone a better provider. In many areas of medicine PAs are put into the exact same roles as MDs, same clinic rooms, same MAs, same facilities, same roles and responsibilities. So referring to the two professions as comparing apples or oranges like the author said in the comments does not reflect the reality but rather reflects the author’s and many MDs view that PAs can never do as good as job because of their differences in training.

  62. So I understand where you are coming from and hear your point. You may not be aware, neither the title nor the tag line are mine. My original title, “Honesty, truth and transparency.” I am trying to have open dialogue about transparency.

  63. thank you for a great article. Midlevels ate so valuable to the health care team.
    Many do recognize that, and are proud of their work. It’s sad to see one who feels she needs to misrepresent herself as a doctor. Sad for her, sad for her profession, and sad for her patience.

  64. Yep, i think people have insecurities is all i can say. I didn’t see that in the article. My PA actually corrects people when they call him doctor but i see another PA and many NPs who don’t. So unfortunately, while you may be the ethical one out there, many aren’t. I think patients deserve transparency.

  65. I don’t see this article as an attack on PAs but rather pointing out behavior that is unethical at best, downright lying at worst, of a medical professional. I don’t know why this always turns into an us vs. them, ego vs. ego, or PAs vs. Drs. This is not what it was about! How did you miss it? My husband is in commercial construction business and never once has he or will refer to himself as an architect!. A PA is entering into a dangerous territory with regards to safety of patient care by misrepresenting their training and certification. From the front desk staff to the highly trained specialist, everyone should know the importance of the key role each of those individuals play in good patient care. However, the point of the article was not to highlight who is more important, but how hazardous and wrong it is to claim yourself as someone you aren’t authorized or trained to be.

  66. As a practicing PA, I find this article disheartening. While your writing is very specific to a single and fairly egregious example of a clinician misrepresenting their credentials, you clearly imply a larger issue with an article title of “The P.A. Problem: Who You See and What You Get”. Furthermore, by signing off your article stating you are “actually a physician”, you further drive home the concept that PAs are somehow out there broadly misreprenting themselves clinically, or are practicing routinely outside their scope. I have a great amount of respect for my physician colleagues. I would encourage you consider the tone of your words here and what they are intended to imply.

  67. If patients prefer to see a PA who is working under the supervision of a doctor, that’s great. If a patient prefers to see a PA as an independent provider, that’s troublesome as Americans assume that only physicians are able to independently practice medicine in the US. The problem that this article is addressing is a PA who is misrepresenting herself as a board certified dermatologist, which she is NOT. Hard to argue patient preference on this situation.

  68. With respect, the title of your article is “The PA Problem: Who You See Is What You Get.” This, in itself, states that that we are a “problem.” Your words, not mine.

    If you were concerned about how this would be viewed, by the PA’s at large, you should have rethought several of your statements, which exudes disdain for non-physician medical providers. Your last sentence is: “Niran Al-Agba, MD is ACTUALLY a physician. She practices in Washington state.” Are you telling me that you did not write that with the intent of putting down other clinicians who are not “ACTUALLY” MD’s.

    I have no knowledge of your father or his death. I did not know the man and cannot comment on him as a person or a clinician…just like you cannot comment on other groups competency as a clinicians. Do you have any idea how hypocritical it is to chastise me for bringing up your fathers education, while you are doing the exact some thing to thousands of dedicated clinicians? Dr. Al-Agba, you waded into this by publishing this article being critical of a profession that you have to work alongside. I am surprised that as a caregiver you lack the self-awareness to know that your tone and demeanor would likely be offensive to PA’s. I would urge you to do a bit of self-reflection…you are not coming off as a caring person with this type of article.

  69. You are seeing what you want to see, rather than the original intention of this post which is calling out misrepresentation. We will have to agree to disagree.

  70. As I have said before (in other posts), there is an excellent independent NP running a practice in my hometown and she and I collaborate often. I find her knowledgeable but also see her as a mentor in my life for many reasons. If I write about a specific NP who is unethical, that in no way “implies” that it is an issue with the entire profession. Please do not extrapolate the post about misrepresentation of this PA to the entire profession; I have never met a PA trying to pass themselves off as a physician either and hope a post like this starts an important conversation about transparency in the medical profession as a whole.

  71. A good health care “provider” is one who has extensive education and training in diagnosing and treating not just routine illnesses but rare ones also. The training physicians receive is tantamount to making sure the patient is getting “good” care-evidence based. This is about patient safety and has nothing to do with egos

  72. Thank you for your service, Adam. This post about misrepresentation clearly has you upset. There are no derogatory statements about ANY profession being made.

    As far as “researching” me and passing judgment on my deceased fathers’ medical career, I fail to see the point you are making. In my humble opinion, it added little to this discussion. However, “I am sorry for the loss of your father” would be appropriate at this time: http://www.kitsapsun.com/story/news/2017/10/29/kitsap-loses-irreplaceable-doctor/808645001/

    Please leave my father out of this. He really was a gem and I miss him.

  73. I agree with you that this is a good start to some important dialogue for all of us who are in the medical professions. I hope constructive conversations continue for all of us. Thank you.

  74. The original title was Honest, Trust, and Transparency. I like “Truth in Advertising” better. That is what this post is really about.

  75. Thanks. PA’s are a valuable member of the team but I agree their training does not approach that of a board certified dermatologist.

  76. Thank you for writing this article. Patients have a right to know who they are seeing and what their provider’s credentials are. The fact that this person would try to obfuscate her credentials speaks to her character. While PAs are a valuable member of a treatment team, their training does not approach that of a board certified dermatologist (8 versus 2 years of post college training).

  77. The mistake you are making here is taking facts personally. Fact: PAs are a Masters level program of education, with no formal post graduate process that can favorably compare to a medical doctor”s. While a PA is educated in the ‘medical model’, as is a MA, and an AA, this level of training is not at the same level of detail, nor does it specifically train to provide the necessary prerequisites for independent practice; hence all non physicians trained in the medical model are called ‘assistants’. What Dr. Al-Agba is articulating is the wanton misrepresentation of midlevels who seek to overstate their qualifications to patients in such a way to take advantage of them. It is truly unethical and immoral to do so. Truth in advertising is the definition of informed consent, and is the duty of all physicians and other assistant healthcare workers to clearly delineate their roles so that the patient has a clear understanding of the extent of the training and knowledge base of the clinicians they are seeing. I am not sure how this is even controversial.

  78. Hello Doctor,
    I agree that my response was somewhat harsh; however, as a PA, I am probably a bit more sensitive to the sensational statements that are being made by some physicians regarding my profession. I have never met, or personally witnessed, a PA trying to pass themselves off as a physician. With that said, in the last week there have been at least two articles, in national publications, implying that the profession is made up of a bunch of “cowboy wannabes,” which is really far from the truth.

    Dr. Al-Agba is a primary care provider, in a fairly rural area in Washington, so should be embracing collaboration with PA, NP’s etc. Instead, she spent the time to write a piece, based on a TV show, and a newspaper article (with a MD who has written a large number of articles which are derogatory about anyone other than an MD working in dermatology) about a single PA but titled it “The PA Problem” and implied that it is an issue with the profession. WE are not a problem, but a part of the medical team…just like the PA in your practice.

    Thank you for giving credit to your PA who sounds awesome!

  79. Everyone needs to point out who they are and work clearly within their roles but as a PA in post-acute care, there is almost no difference in what I do versus what the MD does and patients can’t tell the difference. Trying to say the two professions are not even comparable is absurd.

  80. and you were able to articulate in your short paragraph the importance of not misrepresenting yourself much better than this entire piece. I think what myself and other PAs are trying to point out is that the piece very much is demeaning to PAs as a whole and in actual practice there are many more important factors that distinguish a PA from an MD rather than their training.

  81. It’s incredibly important for patients to know who they are seeing and what that persons training is. A person who portrays themselves as a physician, but who is not is falsely advertising themselves as someone who has training and credentials that they do not have. Being in healthcare is a huge responsibility, and by portraying oneself as a physician they are undermining patient trust in physicians and health care teams as a whole. Mid level providers have a role, but given the more limited training that they have, that role should be supervised by board certified physicians. Note, I do not say that midlevels are inferior, but the role of midlevels is different than that of physicians.

  82. Thank you for this piece. This is about truth in advertising. It’s about integrity and honesty. Ms. Kidd lacked both when she failed to ensure that the public is aware of her true credentials.

  83. Adam, thanks for your service. I can tell that you feel strongly about PAs roles and how they fit into the medical workforce but I don’t see where Dr. Al-Agba dissed the field. I have a PA in my practice and he’s a genius (and overall badass.) But he recognizes the difference between our training and respects that. He’s not out trying to make himself a media star or allowing himself to be mischaracterized. This PA is and that’s what Dr. Al-Agba is referring to.

  84. What exactly makes a good health care provider? If it was simply the years of education then the rest of the civilized world would be duplicating our system when in fact the length of education for Physicians in the rest of the world is much shorter. I contend that PAs are becoming much more popular not just because they are less expensive but because you actually don’t need as much education as you receive as a Physician in the United States. For generations, good Physicians learned from those that came before them and mainly in practice, not in the classroom and PAs can do the same. I would also say however that in my practice, I ALWAYs defer to the Physician and represent them as the “lead” or “main” provider. I so much respect the extra knowledge and have learned amazing amounts from them as well as from reading and understanding EBM. My contention however is that the major difference between a good and bad provider is their bedside manner and caring nature and not their years of education or even their breadth and depth of knowledge. Of course you can be a jerk and be a surgeon but if your care is in any way associated with your ability to connect with people then it does not matter how much education you have.

  85. Thank you for this article. False advertising needs to be called out especially when it affects people’s health care. Mid level providers have a great role to play in supervised practice acting as physician extenders but holding themselves out as board certified specialist physicians is unconscionable.

  86. Dr. Al-Agba,
    Thanks for your candid piece and your focused commentary. Truth-in-advertising is a central American tenet we’ve all come to respect and expect from our service industry. For medicine, that truth is literally life-saving.

    For those people reading more into your piece (i.e. professional warfare, animosity towards mid-levels, etc) shows they have fundamental misunderstandings of health education, finance, and regulation in medicine.

    As a physician, our field has made mistakes (which I hope to address in my healthcare reform plan: http://www.changehealth.today). But when patient safety is at risk because MDs/DOs/PAs/NPs allow blurred lines, we must stop and fix it. This article is a great way to start.

  87. Absolutely it is a problem if a PA misrepresents themselves as a Physician. In many areas of medicine it is nearly impossible to tell a PA and a Physician apart. In my area of skilled nursing facilities and ALFs, we look exactly the same to the patient and have a virtually identical role in their care. “Playing Doctor” is exactly what PAs appear like to the patients no matter what we do to represent ourselves correctly. I am the one repeatedly reminding patients I am a PA after I have introduced myself as one, so I can certainly see how more unethical PAs might take advantage of this and not correct patients and yes that is a problem. This article however is not really about that and if you can’t see that in the tone and comments then you simply don’t want to see it.

  88. Dr. Al-Agba,

    The unsupported, inflammatory, statements that you made in your opinion post is staggering for someone who attended an institution that educates a variety of medical professionals and always instills a collaborative spirit. I have read your piece several times along with your responses to other comments and it is clear that you place yourself on a pedestal making sure to tout (on your web page) all of the honors bestowed upon you by the “community.” As an educated person, I would think that you would understand that the derogatory statements you made about an entire profession were misleading at best. Before you slay all of us for being unethical, uneducated, clinicians, you should do some actual research.

    To bring this closer to home, in an attempt to help you see the err of your ways, let me tel you a personal story. Based on your website, your father (a pediatrician), began his medical education in Baghdad, Iraq. Several years ago, I was based in Iraq for a prolonged period of time, where I became the medical clinician (a PA-C) who would often be contacted by Iraq’s president to take care of his medical needs. While I was always introduced to the President, his wife, sons, and staff, as a PA, they had nothing in their country to compare me to…all they cared about is that I would travel out of our relatively safe enclave in the “Green Zone,” at any time, to either care for them myself, or get them to the set of hands who could help. Would you judge my skills and dedication so harshly and say that Iraq’s president should have seen someone like you, who is “actually a physician?” It makes me wonder, why he and his team would rather have me, a PA, than a physician who was trained in Iraq? How can I guarantee that someone like your father, who was trained in Iraq, meets the educational standard of a PA trained in the U.S? You see, all physicians are not alike, just like all PA’s are not alike.

    Dr. Al-Agba, you should not throw stones in a glass house. I do not make blanket statements about an entire profession based on what I read in newspapers or see in day-time television. There is no evidence supporting that “foreign medical graduates” provide inferior care compared to those educated in the United States, just like there is no evidence that backs your statements about “The PA Problem.” I ask you to consider going back to the roots of your education and accept that a team approach (including non-physician clinicians), is the most optimal way to care for our patients.

    **Note: The medical care of Iraq’s president was publicly well documented; therefore, the information I provided is not confidential or sensitive.

  89. What a great article! This is not degrading PAs or midlevels as a whole at all. It’s all about truth in representation and I can’t think of a place where this is more important than medicine! Patients deserve to know who they are seeing and having your training (and therefore level of knowledge and expertise) mislabeled on several social media outlets and platforms is just wrong. There is a place for PAs and NPs in healthcare. That is practicing under an appropriate supervising Physician.

  90. Absolutely agree. I commented below about the professions not being comparable: there is no us vs. them. It is about teamwork and collaboration. Thank you for reading and commenting.

  91. Thank you for this article. The only people who would have a problem with truth in advertising are mid levels. As a physician, i am more than comfortable to say that I’m not a nurse or a physician assistant. Nurses and PAs unfortunately do often have an inferiority complex for whatever reason and i myself have seen mid levels not correcting patients or peers who call them doctors. So yes, it’s a problem. Nursing is a noble profession and they should be proud of it, as should PAs, who really do help out as a team when supervised. The AMA did a study recently showing that about 70 percent of patients if not more, had no idea who they were seeing. Nothing wrong with being truthful about advertising your credentials truthfully and not play doctor. I have the utmost respect for my bedside nurses, and i wouldn’t imagine playing a nurse. It’s ridiculous that the same courtesy and respect is not extended to physicians.

  92. I can live with everything you said, except there are no statements about PAs being inferior. They are not comparable medical professions. The only difference mentioned is that the years of education to become certified are fewer for a PA than an MD. That is a fact, not an opinion and not a merit-based statement about the profession. Furthermore, the New York Times published the information in the top paragraph about over-treating. You will have to take that up with the authors of that piece. Good luck to you.

  93. No where in this article does it say all PAs are bad. However, there is no denying the fact that physicians have significantly more education and training than PAs and NPs. Not an opinion, it is a FACT. Medicine is not just about spending time with patients and being caring, it is about correct differential diagnosis and using evidence based medicine for testing and treatment. This is learned in Medical School and Residency/Fellowship. Your patient may say they prefer you but studies show most patients would rather have a Physician. I don’t blame them-2000 clinical hours before practice as a PA vs 17,000-34,000 hours for physicians based on specialty. Also for those of you that say physicians don’t care about their patients as much as mid-levels that is the biggest load of I have heard. Physicians literally go into hundreds of thousands of $ in debt, spend at least 11 years after high school learning medicine, work 30 hrs straight and 80 hours a week during training PLUS studying after those 80 hours. Trust me there are much easier ways to make $ than medicine. The dedication and commitment from physicians to providing the best quality and safe care for patients is present every day. This isn’t us vs them. You are literally comparing apples to oranges. All are important to healthcare team. Making patients think you are a physician when you are not is not ethical. Patients don’t want unethical healthcare providers even if they are nice. #beinformed #itsoktoask #doyouknowyourdoctor

  94. I think you can see the comments coming in are pointing out how several comments and the tone of your article is demeaning to the PA profession. Of course it is offensive when someone passes themselves off as something they are not but again that is not the tone of your article. Not to mention it is not clear if Ms. Kidd is the driving force behind all the misrepresentation. Perhaps she doesn’t misrepresent herself but rather others have done so. I get referred to as an MD all the time by patients, even after I have introduced myself or corrected them that I am a PA. Even if Ms. Kidd is doing the misrepresenting, you wrote something that has several statements inferring that PAs are simply inferior to MDs, when in every category we might judge a provider, knowledge, bedside manner, emotional intelligence, competence, clinical outcomes etc this is simply untrue. I would love to have read a piece talking about the dangers of misrepresentation but you used that idea as a front for your opinion about PAs. I am not familiar with your written work and after reading this I won’t be in the future.

  95. Look, her bio previously read that she graduated from the USC School of Medicine. More than a dozen magazine articles refer to her as Dr. Kidd. Her google business page used to read dermatologist. A dermatologist is an MD/DO. Sorry but true.

    As for the California State Medical Board, why do they have laws against mid-level providers practicing independently? Why do they have laws about who can be a supervising physician? Why is it ok to mislead a patient about educational background and credentials as long as no patients complain? I think that approach is terribly unethical.

    What on earth is wrong with being a PA? I don’t understand why we can’t just call her Ms. Kidd, PA-C?

    I absolutely agree that people can get great healthcare from people who are not MDs. I did not say anything to the contrary in my article. Thank you for reading and commenting.

  96. A beauty magazine referred to Christie as an MD. Magazines make erroneous statements all the time. Her really happy patient Kendall Jenner called her a dermatologist. Patients sometimes don’t know what to call PAs and they often want to be polite. Did Christie introduce herself as an MD? Does her jacket say MD? Have any patients of hers come forward who were unhappy with her care and were misled about her credentials? The board of medicine apparently isn’t concerned. Did you consider that her patients know she is a PA and are very happy with the care she gives? People can get great healthcare from people other than MDs.

  97. So every time I write an article about ONE specific mid-level provider who is unethical, various readers try to put me in the box of saying ALL mid-level providers are bad. Unfortunately, that is something about your personal ego, not mine. I have written many times about the importance of team dynamics and collaboration in healthcare. Of course there are good and bad MD’s, DO’s, NP’s and PA’s.

    This article IS about misrepresentation and it happens to be a PA this time. I will ask the question again of all the PA’s who have commented: Why is Ms. Kidd allowing herself to be labeled as the “go-to MD” instead of the “go-to PA”? This should upset all of you who love being a PA. I do not believe writing about this conundrum is a negative commentary on the physician assistant profession as a whole, nor is it intended that way.

    As to your final question, obviously, you are not familiar with my written work, otherwise you would not have asked me about my relationship with patients. Thank you for your comments.

  98. It is the inconsistencies in how Ms. Kidd presents herself that are unethical. A magazine referring to her as the “go-to MD” is not an inconsistency, it is a lie. I think it is dangerous to say “PAs are able to specialize in any field they wish to” when states are granting independent practice rights. There are many PAs, NPs, MDs and DOs who wouldn’t dream of having a specialty clinic outside of their area of expertise, however giving ANY medical profession wide enough berth to call themselves a dermatologist, neurologist, or cardiologist without 3 years of additional fellowship training is entering very dangerous territory. MD/DOs are regulated, which is appropriate, why aren’t mid-levels being regulated by specialty training when they are practicing independently?

  99. You sound like an honest and transparent provider. I agree with you considering the person in question here is very important: whether it is a PA, NP, MD, or DO. Transparency is the major point. Your comment about teaching and mentoring is right on. Mid-level providers absolutely have an important role in medicine. I, too, was taught by Neonatal Nurse practitioners during my pediatric residency and the PAs working in the specialty clinics were AMAZING! I am not insulting the career choice of a PA-C. What I am offended about is magazine articles referring to a PA as the “go-to MD”. What is wrong with being the “go-to PA”? Experience is our best teacher and medicine was an apprenticeship profession for centuries. Again, why would someone who chose a career path refer to themselves as an MD when they are not?

  100. You try to pawn off this article as one about full transparency and the dangers of misrepresentation and yet what you really wrote was a scathing attack on all midlevels and their role in healthcare. You offer one example of an unethical PA and use that as an example for not just the dangers of misrepresentation but of the dangers of seeing a PA or NP at all. I could offer a lot of “brutally honest” statistics of the positive impact of PAs in many fields in healthcare but instead I will just share my anecdotal experience as a PA practicing in Geriatrics now for 8 years. As a result of working in multiple skilled nursing facilities, I have worked with and around dozens of MDs over the years from many different backgrounds and while I have found most of them to be wonderful providers and mentors, I have also seen some absolutely terrible ones that I would not let near anyone I know or love. I do not use these terrible MDs as examples for what is wrong with MDs as a whole, including their sometimes abysmal bedside manner. Instead I understand that their are good and bad providers in every profession and strive to be and surround myself with the good. I write articles and give lectures all the time and would no more criticize an entire profession for some bad apples than I would ever try to pass myself off as something I am not. Your article is more of a window into your perception of midlevels and likely your problem with your ego than it is an interesting article about misrepresentation. I consistently have patients tell me they prefer my care to the MDs and I tell them: “the MD and I work as a team but thank you” I am damn proud to be a Physician Assistant and know exactly the kind of impact I make as I see and feel it every day from patients and staff. Can you say the same? I doubt it.

  101. Do you realize the physician in this article is dead? Hmm pretty questionable ethics to go after a deceased physician who can’t defend himself.

  102. PA-S speaking here. I’m going to address your post in the order in which I see something I would like to comment on. The way you word this entire post shows your real opinion and feeling about the physician assistant( yes it is spelled this way, and no there isn’t a apostrophe followed by an s) profession. I understand there are some inconsistencies with how Ms. Kidd may have presented herself, but this is an attack on the career and a lack of appreciation for what the career brings to the medical realm. PAs are able to specialize in any field they wish to and you make it seem as if PAs are all acting in this manner. And please do not say you aren’t as your entire post reeks of opposition against the career. That is understandable and you are entitled to feel that way. Please take some time to actually look into the profession rather than bashing it, using a few instances as something to make your point. And believe me, I can’t even count on my fingers the amount of times I’ve heard of people arrested for Dr. impersonation.

  103. I too am a PA who always ensures my patients know exactly who they are seeing. I understand where you are coming from, feeling concerned regarding the education differences between MD/DO and PA/NP. However, I think you should also consider the individual. Many of us, for instance, are fortunate enough to work with fabulous supervising physicians who teach, tutor and encourage our growth as clinicians. After several years under the tutelage of such physicians and continued diligence on my part to expand my medical knowledge and understanding, I find myself in a position of providing education to medical residents. My fellow providers (yes, even physicians) often seek out my opinion on treatment plans or for help establishing differentials for a complicated patient. I too have the respect of specialists and other health care providers in the surrounding areas because I have spent years practicing excellent medicine and helping patients. In short, there are providers from every field who excel and those who just get by. There are providers from every field with whom I wouldn’t entrust my dog, and those with whom I would trust my life. I may be “just a PA”, but ask my patients whom they feel safest with and compare my performance statistics with any other provider (including doctors) and I think you will see that time and experience can do a great deal to close the “education gap”.

  104. The issue here is transparency. Why does she refer to herself as Dr. Kidd? Shame on you for supporting this kind of misrepresentation. No one has said “PAs are all bad.”

    In healthcare, honesty and transparency are paramount. I will stand by that statement. Patients have a right to know the education of the person providing their healthcare. Why is this so disagreeable to you?

  105. I have been a PA for 20 years and serve in an underserved area with mostly low income struggling minorities. Our practice has tried to hire Physicians but they work in our office for about a year or less then quit. Over 20 years I have become very independent and rarely need the guidance of my supervising Physician. I always correct any patient that calls me doctor. After a patient meets me they generally prefer me over a physician as I can spend more time with them. My patients tend to be very complex with multiple diagnoses. In our area other providers know my name and associate me with excellent care….there are always “bad apples,” and I have meet some physcians that I am truly shocked how they even made it through medical school. Many physicians convey a sense of entitlement and arrogance, mid levels are much more approachable in general. We bridge the game in primary care, and if physicians feel threatened then they need to rexamine themselves. That PA Kidd, that your blog wrote about must be an excellent provider as I doubt such well known would return to her practice otherwise. Yes, it would have benefited our profession to actually prominently display herself as a PA, being clearly very good at what she does. But to focus on something trivial as compared to all the fantastic work PAs take part in.. surgery ( enabling him/her a break), pain mangement, psychiatry, underserved areas and specialties is a tragedy. Shame on your doctors, shame on your blog. Talk to the patients…seek all the good we do. There are plenty of incompetent doctors …but no one talks about them…and plenty that come to the US to make more money rather than help their people…

  106. Interestingly enough, that augmented education is about 1,000 clinical hours. Again, this is a fact about NP education not a commentary about superiority or inferiority.

  107. In healthcare, transparency about background, education and expertise are so important.

  108. Glad you saw the point I was trying to make that this is a piece about misrepresentation, not a commentary on the physician assistant profession as a whole.

  109. Thanks for bringing this up. This is CLEARLY a PA problem as there has never been an unscrupulous or fraudulent physician.

  110. This is a common problem in society and not just the medical profession. It’s also dangerous. Think of the electrician that has the certifications necessary to do the electrical work on a new home or remodel. He might have the required expertise and licensing, but a different not so competent electrician rents his name. Suddenly, a person with less expertise and perhaps too little expertise is the one throwing the electrical wires all throughout the house leaving live wires exposed, ungrounded outlets, etc.

    One doesn’t like to think about such problems occurring in their home so I doubt one would like to think about that when their health is involved.

  111. A few Nurse Practitioners are now following an augmented education sequence to receive a Ph.D. level degree. Increasingly, the legislatures of certain States have approved amendments to their professional licensing regulations to permit independent practice for mid-level practitioners. Would we really accept a mid-level practitioner as representing adequate Primary Healthcare for a child with disabilities or for an adult on five or more medications taken at least once a day? Its a licensure issue and not a payor quality of care problem, right? Further more, I don’t recall that any of the national ‘health system’ certification processes have ventured into this problem.