Communication is key to the MD-PA team

FigureFigureMy first interaction with physician assistants (PAs) occurred when I was 8 years old and was rounding with my father in the hospital. My father was a PA. Through him, I saw what PAs could accomplish: the ability to flex to all areas of medicine, the capacity to maximize responsibilities through strong mentorship, and the ability to positively affect patient care. My father was a PA on the Alaska pipeline, worked on Indian reservations in North Dakota and South Dakota, assisted in cardiothoracic surgery in Alberta, and practiced inpatient and outpatient medicine in Arizona, Missouri, and Florida. The stories he told and the variety and flexibility of his career showed me what a productive MD-PA relationship could be. I carried those memories with me through medical school, through residency, and eventually to my first leadership position as a hospitalist at East Carolina University (ECU). When we started the hospitalist program at ECU in 2002, one of the first things I insisted on was incorporating PAs into our program. Some physicians in our group didn't understand how PAs would work with us, but I knew. My father had taught me. After 15 years of working with PAs and PA students at ECU, the Mayo Clinic, and Wake Forest University, I identified core building blocks that I believe are essential to developing a productive MD-PA relationship. First is the structure of the relationship. Some will espouse that MDs and PAs need to be “at the hip” working together. Others will say, just give PAs work to do and they can always call if they need you. I believe in neither approach. What I believe in is maximizing everyone's abilities, be they PAs or MDs. My favorite day working with a new PA or PA student is the first day, for it is on the first day that I usually surprise them. “These are your patients today,” I say. “You are their primary provider, not me. See the patients, listen to them, examine them, review all their numbers and tests, and then come back and tell me what you want to do for your patient.” One hundred percent of the time, a new PA or student working in our program will make a mistake or miss something. That is exactly what I hope for. I want them to be wrong. But I also want us to talk through their thoughts and their decision-making process. I believe that when you push against your limits of knowledge, you learn and you get stronger. Because the patient's potassium is consistently low, what is the magnesium level? What did we do with the vancomycin dosing since the trough is low? Why is the patient's C-reactive protein (CRP) elevated? Why did we get a CRP in the first place? What is the big picture here? What is the timetable for the patient's discharge? That structure will not be successful, though, without the second key part of the relationship, the support. Anyone in a new position is going to be unsure. My job is to reassure our new PAs and students that I am here for support and that our goals are aligned: we are here to help our patients the best way we can. I also relay that I am on the unit as well, and will be looking at our patients from a reasonable distance. I'm always accessible for any questions and encourage questions. But they are the ones who need to come up with a plan for the day. The art of the relationship is creating an environment where it is okay to fail. My sense over the years is that we all naturally are afraid to make a mistake. But our new PAs or students who push themselves to their maximum are almost always the best because they are pushing their limits. And that is when I know things are going well in our relationship. The satisfaction comes in seeing the rapid progress made using these principles. The student who struggled to see one patient on the first day is seeing five patients by the end of the week. Then I begin to receive fewer pages from the PAs because they have become stronger in their skills, their knowledge base, and their craft. Their growth is very satisfying to me. That blends in with the third essential part of the relationship, communication. If I am not accessible or open to conversation, it hurts not only the MD-PA relationship but also the provider-patient relationship. We, as a team, have to communicate. Paging me to ask a question is not a weakness—it is a strength! Without positive, open communication, things get lost, and things get missed. Ultimately those losses trickle down to the patient. I have always believed that two brains are better than one. If we are both thinking and communicating together about a patient, that patient benefits. And, as an aside, we do not forget about the nurse's brain that is at the bedside. If you have the nurse's brain working together with you also, you have a great working relationship and patients benefit from that. What do I think is a good MD-PA relationship? It is extending PAs to be the best they can be while supporting and communicating with them in their efforts to give patients the best care. That is the MD-PA relationship I have learned and honed over the past 15 years. I believe that relationship has been very satisfying for the 100 or so PAs I have worked with in my career. Those building blocks are what I learned from my father and how I try to give back to the PA profession in his memory.

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