During a recent and unusually slow shift in the emergency department (ED), I had an interesting conversation with the physician with whom I was working and, by mandate, to whom I was presenting all patients with Emergency Severity Index (ESI) scores of 1 to 3 (indicating moderate to severe conditions). This physician is not my legal supervising physician, an arrangement that is common in PA-physician collaborative practices in EDs. The conversation led to his acknowledgment that this “forced collaboration” must be not only a source of professional frustration for experienced PAs but also a barrier to the development of PAs’ personal (evidence-based) style of practice. He also presented misgivings about signing charts for providers he does not legally have to supervise. 

As PAs have steadily branched out to all medical subspecialties, the model of physician-PA collaboration has evolved (or devolved, depending on the perspective). The original role of the PA as an extender of their supervising physician’s practice — a platform based on trust and familiarity in primary care specialties — has morphed in the hospital setting into a compensated extension of the medical-student role. This latter role is often appropriately summarized as present-and-defer (to a physician with whom the PA may or may not have developed trust and familiarity, as is the case in the ED). Conversely, physicians with no legal bond to a given PA’s licensure may be stuck with an anxiety-provoking obligation to sign unfamiliar providers’ charts even though 49 states do not legally require on-site physician presence as a constituent of PA practice in the ED.1 The reimbursement drivers of this framework are beyond the scope of this article.

Findings from a recent study in JAMA Health Forum, in which researchers examined variations in care between physicians, raise some questions about the potential downstream effect of inconsistent (and sometimes inappropriate) physician practice on PA practice.2 Primarily, what is the impact of these variations on the development of evidence-based practice translational acumen and subsequent development of practice style among PAs, and how do the inconsistencies affect the inevitable issue of assessment/plan discord and the consequent potential for perception of insubordination among PAs?

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Asked more succinctly, how do PAs develop clinical prowess and, perhaps more importantly, good clinical instincts in the setting of required yet inconsistent and indefinite physician instruction? What is the realistic recourse for a PA who does not agree with a physician’s instruction? Furthermore, how does physician bias inform collaboration and guidance such as in physicians who practice more defensively or are burnt out?

In my conversation with the ED physician, he disclosed anecdotes from his residency where he admittedly tailored his assessment and plan to whichever attending was on duty rather than executing his own authentic decision-making. This approach is reflected in conversations I have had with other emergency medicine PAs and certainly in my own experience. 

It may be time to grant experienced PAs the relative independence they have earned and evolve the de facto mandated collaboration to one more akin to selective collaboration as PAs are trained to know their limitations. Consideration to completed fellowships/postgraduate training and Certificates of Added Qualifications (CAQ) completion should be given, though for now their effect on care quality and outcomes represents a gap in the literature and informs a potential research focus.

Ultimately, there is a reason the term physician extender never stuck and there is a reason we all cringe when an apostrophe is mistakenly included in our title. We are extenders of medical care and not the extensions or property of any one group of providers who are as the JAMA article demonstrates as prone to fallibility and variation as all of us.

Benjamin Miller, DScPAS, MS, PA-C, practices at BlueWater Emergency Partners, where he provides care to patients at East Boston Neighborhood Health Center Emergency Department in Boston, MA, and Nantucket Cottage Hospital Emergency Department in Nantucket, MA. He also works for Vertava Health in Cummington, MA, providing care to clients recovering from addiction.


1. Wiler JL, Ginde AA. State laws governing physician assistant practice in the United States and the impact on emergency medicine. J Emerg Med. 2015;48(2):e49-58. doi:10.1016/j.jemermed.2014.09.033

2. Song Z, Kannan S, Gambrel RJ, et al. Physician practice pattern variations in common clinical scenarios within 5 US metropolitan areas. JAMA Health Forum. 2022;3(1):e214698. doi:10.1001/jamahealthforum.2021.4698