Industrialized societies thrive on specialization. As systems grow more complex, we divide tasks and responsibilities. In best-case scenarios, specialization makes our processes more accurate, efficient, and economically productive. However, specialization can also lead to fracturing and disorientation. During my thirty years of designing healthcare facilities, clinics and hospitals became more and more complicated. In part, due to the increase in medical knowledge and diagnostic possibilities; in part due to increased technology; in part, due to more and more clinical staff with increased levels of specialization.

Madeline Basse and Lisa Neff are PA (Physician Assistant) students from Colorado studying at Midwestern University in Glendale, AZ. In the lexicon of medical professions, PA’s are relatively new. Duke University developed the country’s first PA program in 1965. The two-year training model responded to the shortage of physicians and provided army medics returning from Vietnam, veterans with solid medical skills, a path to civilian credentials. Now, there are dozens of PA programs throughout the country. PA’s fulfill a variety of clinical roles in emergency, outpatient, and inpatient services throughout the United States. The title Physician Assistant is misleading, as it implies a direct connection with a doctor. PA’s work under a supervising physician, but that supervision is often at arms length. Many PA’s are the primary care provider for their patients.

Traditional medical school requires two years of classroom and dissection training plus two years of clinical rotations among a variety of specialties, followed by a one year internship and two to five years of specialty fellowship. It takes a long time to be a cardiologist. PA training is twenty-seven months total. One year of classroom and dissection followed by nine clinical rotations, each five to six weeks long. My dinner companions were mid-way though their clinical rotations; Madeline in OB/Gyn and Lisa internal medicine.

PA’s do not specialize. Madeline explained, “One of the things I like about being a PA is that I can do emergency medicine for a few years, and then go into a clinic. Doctors are so specialized they don’t have that flexibility.” Lisa was clear about why she chose to be a PA rather than a traditional physician. “I want to get married and have a family. I didn’t want eight years of training.”

Most PA students take time off after undergraduate school. Madeline and Lisa gradated with science degrees, worked for a few years, and realized that being PA’s was a better fit for their life objectives than being a traditional physician. Madeline explained, “The application process for PA School is long. It takes a full year of applications and interviews. Most people can’t do it while undergraduates, especially since many of us are trying to figure out if we want to go to regular medical school.”

When Lisa and Madeline graduate in August there will be many opportunities available for them. Lisa’s boyfriend is a medical student at Creighton, which offers third and fourth year clinical rotations in Phoenix, so she is planning on finding a job here. Madeline would like to return to Denver, but is realistic about her prospects. “Everyone wants to go to Colorado, so there are fewer jobs, and the jobs there pay less. I’ll be looking at other places in the West – maybe Wyoming or Montana or Idaho.”

How will we live tomorrow?

“There will be a lot more PA’s. There’s a mass exodus from primary care of traditional physicians. New PA Schools are opening every year.” – Madeline Basse

“We learn so much from the doctors who are our preceptors. The doc I work with now doesn’t tell people what to do. They are mostly older patients; their habits are set. If we think the doctor’s job is to tell people want to do, people just won’t come. My dad hasn’t been to a doctor in twenty years. He knows the doctor is going to tell him to quit smoking and loose weight. He doesn’t want to hear it. We have to accept people as they come to us. We all have our addiction, whether it’s smoking or eating or sugar. We have ten minutes with a patient to guide them to feeling better. We’re not going to change them in that time.” – Lisa Neff