Expert Insights from Program Leaders
March 21, 2022
Season 2: Episode 32 - George Washington University PA Program

Steph and I have a delightful conversation with Drs. Ritsema and Hermann from the George Washington University Physician Assistant Program. We learn about their program and about their roles in the Physician Associate movement in the United Kingdom and w...

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Steph and I have a delightful conversation with Drs. Ritsema and Hermann from the George Washington University Physician Assistant Program. We learn about their program and about their roles in the Physician Associate movement in the United Kingdom and with the National Health Service Corps. We also discuss some different perspectives on the doctoral degree for PAs.

The purpose of this podcast is to provide news and information on the PA profession and is for informational purposes only. The views and opinions expressed in this podcast are those of the speakers and guests and do not necessarily reflect the official position or policy of the University of Arizona.


Season 2: Episode 32-George Washington University PA Program


pa, profession, gw, students, people, graduate, pdas, uk, public health, program, doctoral degree, education, physician, didi, national health service, phds, tammy, health, week, area



We respectfully acknowledged the University of Arizona is on the land and territories of indigenous peoples. Today, Arizona is home to 22 federally recognized tribes, with Tucson being home to the Ogden and yaqi. committed to diversity and inclusion the university strives to build sustainable relationships with sovereign Native nations and indigenous communities through education offerings, partnerships and community service. Welcome to this episode of the PA path podcast, I'm your host, Kevin Lohenry. We are glad you could join us as we seek to better understand the PA profession



that if people pursue doctoral education, they should pursue something that's going to provide them a specific set of skills.



Well, hello there. And thank you for joining us again on the BFF podcast. We are excited to bring you a really interesting conversation today. With our colleagues from the George Washington University PA program. We speak with Dr. ritsema and Dr. Herman about GW their role in the PA profession, Dr. Written his role in the beginning of the UK model, and also about the controversy around the PA doctrine. So we hope that you'll enjoy this and if you want to learn more about our guests, and about George Washington University, we invite you to check out our website at the PA pad podcast calm. Well, Tammy and Didi, thank you so much for joining us today. We're so excited to get a chance to learn more about George Washington University and about your impressive paths to becoming a PA. Why don't we start with Tammy and Tammy, if you would be so kind to share your path to becoming a PA with our audience? That would be great.



Certainly. So I would say my path is pretty a typical actually, I had a degree in political science and Chinese studies from the University of Michigan. And I was actually had a serious illness when I was in university. And I was really, really frustrated with how the healthcare system interacted with me. And on the back of that actually decided to pursue graduate training in public health, initially with an emphasis on health education, because of my my own experiences. And I started in the School of Public Health at University of Michigan, and liked the health education stuff, but actually fell in love even more with epidemiology stuff. And so I focused on both of those in my training at Michigan. And when I graduated, I started working in family medicine at the University of Michigan, helping junior faculty get their research programs off the ground, they had a little frustrated with me, because I kept asking, like, normally people in public health or in data want to know just like, well, how is this data structured, whatever. And I was like, why are you using a beta blocker? Why are you using an ACE inhibitor and they're like, please, for the love of God, go to medical school and get off my back. So we had a wonderful pa in our Department of Family Medicine there who you know, inspired me to consider PA school. So I had to do a post baccalaureate pre med program because I had no biology, no chemistry, no physics, nothing. And I came out to the east coast to do that, and then applied to Emory. And Dede and I are graduates from the same year. So she's from Georgia and went to GW and I was from Baltimore and went to Emory. So we sort of cross paths. And after graduation, I worked in neurology and emergency medicine at Johns Hopkins for about a decade before entering pa education full time in 2009.



Wow, that is that is very interesting. And what I found, I don't know about you stuff, but for me, many of our educators, they start off with what my path is a little not as typical. So I don't know if there's so we need to do a study Tammy about



starting to think that that's common in education.



Yeah, we're all a little bit off the beaten path, I guess. So. A DD How about you?



Well, I'm actually going to describe a more typical pathway. I would say I I was a first generation college student and I knew going into undergrad that I wanted to do something in healthcare, but I wasn't sure exactly what that was going to be. I went to college hoping you know that I was going to be successful, didn't really know what, how it was going to sort of work out but luckily I was and I ended I'm getting a degree in clinical laboratory sciences because I really needed to take some time after graduating from undergrad to pay off some student loans and and just give some thought to what did I want to do sort of for my long term career. So I, you know, worked in a hospital laboratory as a generalist where I, you know, was in the blood baking department, chemistry, hematology, microbiology, and I had a lot of interaction with physicians and other health care providers, never a PA, I'm sad to say, I didn't even know about the PA profession until I started doing a little research on you know, I was sort of in that space where everybody's like, well, maybe I'll go to medical school. And then when I started really thinking about medical school, and the time commitment and other things that I wanted to accomplish, and into my life, it just didn't seem that practical to me. And so I started looking at pursuing a career in public health and actually getting a master's in public health. And through that process, I came across the GW pa MPH program, learned about the PA profession and thought, oh my gosh, that's exactly what I want to do with my life like this is the perfect combination for me. And so I ended up applying to the GW PA program absolutely loved my interview and visit here felt like it was a really good match and fit, and was luckily offered admission into the program, you know, to when I was thinking about my gosh, how am I going to pay for you know, because as I said, I was first generation college students from a family that didn't really have the means to sort of support me financially through this adventure, I needed to figure out a way that I was going to pay for my PA education. And so I started looking into opportunities and came across the National Health Service Corps Scholarship, I applied, once I knew I was, you know, admitted to the GW PA program, went to the interview, thought it went fantastic, but was not offered this scholarship. And then in the next year, I applied a second time and was luckily offered this scholarship. And so they paid for two years of my three years at GW, which was a huge help for me, and also a really wonderful experience an opportunity that I can talk a little bit more about later if we had the time.



Yeah, let's let's delve right into that. Because I think the National Health Service Corps is an amazing program for students, and particularly for programs like ours that are maybe a little bit more expensive or not state schools. What a great way to take care of your your PA debt and start your career with without any significant college debt.



Yeah, it was it was absolutely for me, I was just so happy that I came across it because, you know, it really mirrored it. The mission of the NHC is to put primary care health care providers in areas that don't have access to primary health care, basically. And so I've given you a little bit of a glimpse into my, you know, upbringing, upbringing and everything. I, you know, I grew up in a very small rural area, I had family members that were really in rural areas, and I saw them struggle constantly with the challenge of just not even being able to get basic primary care, and then specialty care, my goodness, it was hours away from their home and their support systems. And it just really dawned on me that the system was just broken in that manner. And then when I read the sort of how the PA profession sort of started and how it was meant to really addressed the primary care shortage in the nation, I was like, wow, this is a perfect match. And so I was really happy that my personal goals, and the nhcs mission were very much aligned. And so when I graduated, I started working in a community health center in rural West Virginia. And it was an excellent experience like I, I saw mostly adult patients, from ages 18 to 65, the medical director was my supervising physician, I shared an office with another physician, and we provided you care, six days a week, we would go out to the migrant farm, far to the farms in the area and take care of the migrant workers there. And it was a lovely experience, quite honestly, I would have stayed there for the rest of my life. But my, my personal life was sort of going in a different direction. And for me, it was a wonderful experience. And in fact, you know, when I came back to the DC area, I really searched to for a job within a, you know, a federally designated qualified designated clinic. But it just so happened that the folks that were serving in those roles in DC were very committed to it and they're just spreading any openings for PA is at that time. And so I went into emergency medicine because I thought, well, getting my procedural skills up to speed would help me because it's always been my long term goal to also in my career in a health professional shortage area in a rural areas. So I definitely see and have a plan to do that later in my life. And so, worked in emergency medicine, and then started teaching in the program. And I now also work at a clinic and family medicine that serves families that may not have the ability to pay for their health care. It's not a federally designated health care center, but it has that sort of sense and I precept some of the GW PA students that rotate there that are also going to be National Health Service Corps scholars are lone repeaters.



That's wonderful. So So you still probably the presence of you there as a former NHSC scholar, helps promote and you're kind of an ambassador for the students at your program, I would imagine,



yes, I do end up talking to many of them and encouraging them to apply and sort of giving them a flavor of what to expect when they get out and how they might organize their clinical rotations to prepare them for the experiences that they're that they're going to face when they're, you know, a graduate PA and providing care in, you know, relatively resource poor areas. So, yes, so I'm very committed to that. And I'm really excited that I have that opportunity still to really prepare the future generation of those who are serving in areas of health professional need.



That's great. George Washington is one of the handful of programs around the country who offer not only a PA but an MPH option. Can you guys talk a little bit about the PA mph combination and how you feel that makes GW unique, and maybe what that addition of an MPH offers applicants and students,



I actually work with Howard Stryker to organize that program. You know, I obviously have sort of a bias toward it, because I came from a public health background before I became a PA. Howard striker did it the other way around, he actually got his mph after he was PA and then Diddy did it concurrently. So there's different models. But I think we all really value the opportunity to teach students to assess not only individual patients, but to assess communities and to assess systems, right, I can prescribe 8 million inhalers to everyone in my town who has asthma, or possibly I could do something about the plant that's spewing pollution, and making everyone we ease. And ideally, maybe I could do something about both of those things. Right. And so the dual training allows it, I think it also provides a breadth of an approach to medicine that people who study only medicine may not get quite as much, we really enjoy the opportunity to offer several different tracks within public health. So I know that some PA programs, they just have a defined track for their PA students, but our students can choose epidemiology, community oriented primary care, health promotion, health policy, environmental health, global health, maternal and child health, as their focus. And I think students really appreciate that, that opportunity to do that. I know for myself, I feel like my Public Health Training impacts my work as a clinician, because I'm thinking about something bigger. So I'm not just saying Do I need an X ray for this person? I'm thinking about if I order an x ray, what's the cost to the system? If I order that X ray, what's their lifetime radiation burden? Things like that, that come from my public health training. And again, I don't want to minimize the population health training that we do provide in PA education. But certainly spending a year on it versus spending a few hours a week on it makes a tangible difference. And you know, we see that a lot of our PA mph grads, our most successful applicants to National Health Service Corps actually have been our PA mph grads because I think National Health Service Corps recognizes the value of population health in medically underserved areas a lot. So it's really exciting to be involved with. I will just say one last little thing you can edit it out if you want but our PA students are absolutely beloved by the faculty in the School of Public Health. Our PA students are super motivated, super motivated and bright, and really have a vision for what they want to do. And that really endearing On to our Public Health faculty.



You did. Did you want to add anything to that?



Yeah, it for me having that Public Health Training and that skill set those skills, going into my first job as a PA in a medically underserved area was very important because, you know, in, you know, in your PA education in your clinical medicine course, you learn the optimal treatments and procedures and whatnot. But you don't hear like, what are other options if those things are not available to you or to your patient population, or, you know, that kind of thing. And that's what I learned in my public health classes. Because, you know, I was in public health classes with physicians or other health care providers that were providing care in, in, you know, urban DC and our federally qualified, you know, community health centers. And so I was getting a real glimpse into the challenges that they were facing, and, and and how resourceful and creative and innovative they were having to be. And then, you know, that they were having to apply for grants to get certain things for their patients. And they needed to know how to navigate the system and the network. And so I found that incredibly valuable for my experience in the Community Health Center as a National Health Service Corps scholar, I'm not sure how I would have done it without that training, honestly. Could you tell us a little



bit more about just generally the George Washington PA program, how it's structured, and maybe expand a little bit on tips that you might give applicants who are who are considering GW?



You want to go or you want me to go DD?



Go ahead. Okay.



So we are, I would say, in some respects, a fairly traditional PA program in that we have a didactic year and a clinical year. Unlike many other programs, we're actually still a 24 month program. And I think that's an advantage in some cases and a disadvantage in some others. So I think that it's, it's an advantage, if you want to get done quickly, you go into a private school, it's expensive, it's nice not to have to pay for another semester. It can be a disadvantage, I think for students that maybe don't have as challenging an academic background from undergraduate. It's really, really drinking from a firehose because it we move so quickly, our basic sciences are 10 weeks in the summer, and you're done. And it's a lot. So we have, you know, sort of 12 months of preclinical and that's fairly lecture learning group learning session based with some small group work. We're not like a PBL program, for example. But we're very fortunate to be part of a large academic medical center and be able to tap resources. You know, we have an excellent department of anatomy, physiology, pharmacology, microbiology, things like that. And our students are actually taught by PhD anatomist or physiologist, things like that, in addition to all of our normal clinical departments that you have at a large academic medical center, our students in the second year take six week rotations. In the seven core disciplines, plus one elective, they come back at the end of each of those six week rotations to take an examination and have a couple of days of educational input. And we are very proud of our graduates are we frequently get requests from employers that we would like to hire a GW graduate? Can you send us a list of names, our alumni are passionate and engaged? A lot of our alumni teach for us do interviews for us, preceptors students? And I actually think that is a little bit of a testament to the program that they want. They didn't just say, Oh, thank God, I'm done with that place. Right? That they're calling me up from Boston and Chicago and Dallas and saying, Send me a student send me a graduate. So I think one more thing I will just say is I'm very proud of our faculty. I think Kevin and Steph know this, but our faculty are very involved nationally and have been really for decades. We have a number of people who've been presidents of APA presidents of PA work on a lot of different committees, Journal of PA education japa, our clinical journals has been edited by a GW faculty member before and then I've done a bit of international work. And so I think that students benefit from the opportunity to interact with leaders in the profession.



Can you set us up just right, that's perfect. A perfect transition because we were going to, we're going to ask you about your international work here. One of the things that we're doing with our second season is is really starting to expand upon all the different areas of the PA profession is growing. And you've had such a important integral role in the growth of the profession in the UK. So can you tell us a little bit about how you got involved in that? And kind of where things are at in in the UK at this point?



Sure. So, you know, per usual, right, I think sometimes students think that everything is very logical and organized, and you apply for something. And actually, the world kind of doesn't work like that. So how I got involved with the profession in the UK is that I worked at the Johns Hopkins emergency department for eight years, and one of our nurses ended up marrying a guy who was British, and she moved to London. And she worked is as a nurse in a large academic medical center in southwest London. And one day, a doctor came up to her and said, Sarah, you're an American, what do you know about PDAs? And he says, we're thinking about starting the PA profession here. Could you come to a meeting, so she went to the meeting, and thankfully, they asked the right nurse, right, that could have been disastrous. And she went to the meeting and said, we couldn't run Johns Hopkins. Without them. There's 450 PhDs at the time at Johns Hopkins, and they're the backbone of place. And I think that impressed them along with the Hopkins name, that PDAs are not just used places that can't find doctors, right, but that keys are being used at a large academic medical center like that. And she said, you know, if you're thinking about starting a program, one of my best friends is a PA and a PA educator, and she happens to be come visiting me six weeks from now, and you want me to bring her by. So they did. And I met with the people that were thinking about starting the program. And to make a pretty long story much shorter, they invited me to help design some of their curriculum in my areas of expertise, which are neurology and emergency medicine. So for the last we're in our fourth 14th cohort, now, I'm at St. George's University of London, which is the longest continuously running PA program in the UK. And I've taught all 14 cohorts. So even during COVID, I've been teaching online. And you know, at the beginning, there's mean, the UK association of Pa was about 25 of us, some of the people from the original pilot projects, some of the American TAs from the original pilot projects who'd stayed, and then some of the very first UK trained PhDs. And with my research orientation, I actually proposed to them that we start collecting data right from the beginning, on pa s. And I actually spoke with researchers from the beginning of the profession here about if you could go back to 1967. What would you have collected? And how would you have collected it because, as I'm sure many people are aware, the way that for a long time, the way the APA collected their data did not make year to year comparisons, as easy as they could have been from a methods perspective. So so we started collecting that data. And, you know, trying to track that. And we wanted to lay a foundation in the medical literature for the profession as it was growing. We felt like that was a key way of establishing credibility for the profession, particularly with doctors, administrators, with leaders, academic leaders across the country, right people, people want to know what's in the peer reviewed literature. And so we set out to develop some peer reviewed literature for there to be something to refer to from a nadir of two programs in 2013. We are now up to 31 programs, there are programs in all four countries, England, Scotland, Wales, and Northern Ireland, of the United Kingdom. And we're graduating in the neighborhood of 900 Tas a year. There are about 3000 Tas now. And you know, now we'll be putting out about 900 to 1000 a year and we had a long fight, we had a 10 year fight for regulation. And sometimes Americans hear that they're like, you don't want to be regulated. We're like, no, absolutely. We want to be regulated. And here's why. Right now, anyone, like your 89 year old neighbor with dementia, or your four year old neighbor could call themselves a Physician Associate, which is what we're called in the UK. And that's not illegal. And in fact, we do have some people that are not actually PhDs who have claimed that title and are practicing under that title in the UK. And so we desperately want Professional Regulation, because that also would mean title protection and recognition of our national exam and graduation from one of our programs as a prerequisite to practicing under that title. That what that is moving forward. We're very grateful but I'm COVID and Brexit have both put a pretty big hit on moving that forward because the attention of the government has been diverted elsewhere. We were just told about two weeks ago that what was going to happen Then 2022 will not begin to happen until 2023. Now, so that's a bit of a disappointment.



Yeah. And so as a researcher, I'm sure, especially with that rich data set, what are some of the I think sometimes, as Americans, we just assume that our profession elsewhere is going to be identical to us, and were the experts. But in fact, in many ways, other countries can innovate differently than we do. And and so I'm curious what you've learned about the profession through the lens of the UK model? And what are some of those things that really, we should be considering as a profession here in the US that you've learned?



Yeah, that's a great question. I mean, one thing I've learned so much is that way more than I ever understood, our profession has developed in the context of an entrepreneurial private practice, sort of health system. So for example, a big issue for UK IPAs is that it's hard to get promoted, and it's hard to get more money. So in the US, if you work in a GI practice, and the practice has a good year, financially, right, they might give you a raise or give you a bonus. In the UK, they are part of the health system, the National Health System. And so you have to if you want to climb that you have to take on new roles, so you don't get more money just for being more experienced or good at your job. And so that's had a lot of implications for how we need to train PhDs. So for example, if you need to take administrative roles, or if you need to take research roles, we need to, we need to begin equipping them to be able to accept those new duties, to be able to sort of climb up the ranks. And that's not something I think that any of the American PhDs that were involved in at the beginning, ever thought about, because that's not how we get promoted, or how we get a pay rise in the US. You know, one thing that's so interesting, and it's not something we can fix as a profession, unfortunately, but the fact that health care and retirement benefits are not linked to a specific job means there are some incredibly exciting care models that they are doing in the UK. So for example, there's a hospital that has TAs who alternate between general practice and basically being a hospitalist. And it actually provides really interesting continuity of care through the community, right, because you can be their hospitalist for a few days. And you can check back with them later, in what we call GP surgery, general practice, right? You can have people who almost all our PA, educators work only one or two days a week, and work the rest of the time clinically. And they can do that because they don't need to work in one place to get health insurance. And that, again, I think provides a lot of benefits both to the clinical side and to the education side for them. I think that they have integrated credentialing. And so you can and that's really been huge and COVID. They've just been able to somebody just been able to pick up and go to a different hospital in a different part of the country. Tomorrow. There's no because their credentialing is nationwide.



Yeah. So as a program director who fills out credentialing forms for every graduate all the time, and the multiple right for every hospital. That is very attractive. And amazing. Wow. So Tammy, I have a few really amazing British physicians that I work with here in Los Angeles. And, and they work with us because we have reciprocity in between the licensure and licensing laws in California, and their training in the British system in the UK system. So I know a lot of our listeners are wondering because obviously Americans are working in the UK. Is there any path that you can proceed where the UK train PA is might end up working in the US in a similar recipe? Reciprocity?



Yeah, that's a really good question. So right now, just to be clear, for your listeners here, American TAs are still allowed to come to the UK and work under their NCCPA credential, how long that's going to last right at some point, they're going to have to sit the British exam, right. But currently, that's still allowed British pa would love just for the same reason that American pays like to go overseas would love to be able to come I think that one of the facilitators to that is that British pa education is modeled pretty closely after American pa education, which is not true in some of the places that train like clinical officers and things but I think the bigger issue will just be like will NCCPA allow it right now. There's no accreditation process for UK PA programs. I actually have spent a lot of time like I spent almost a year Writing the initial accreditation documents that, of course, are now substantially modified because I'm not British, but I gave them a good start. And and we have extreme heterogeneity between the quality of PA programs because there's no direct oversight at this moment, we have initiated a process for that, and the same organization that accredits UK medical schools, will be doing accreditation of UK PA programs. So that's a big win for us. But I think that it would be unlikely that NCCPA would be interested in granting credentials to people from unaccredited PA programs. So I think that would need to get sorted out in the long run. I will also say, it'll be interesting, if that happens to see how how much direct you know which direction people go, because pay in the UK is about 50% of what it is in the US. So I would think that there might be more British PA is interested in coming this way than the other way around, although they don't have the student loan burden that we have. So



all the more reason, right. So they don't have the student loans. The only difference? Obviously, they have the National Health Service. So that that is Yeah, and we don't yet know if we ever will. But that Yeah, I mean, that would be a very attractive thing to be able to come back over here because you could make the higher salary. Right, you're debt free. Yeah, right. I get that. Yeah. Wow. Well, that's so congrats. That sounds like you've done a lot of really interesting things over there and help them build really thoughtful model.



Well, I just want to say that, you know, I am only one small person. In a, in a group of really committed people. I mean, there's probably 5040 to 50 people that work there from the beginning in one way or another. And we've all slept on each other's living room floors, and we know the name of their dog, and what year their child is in school, because we're really, really close. So I just want to be extremely cautious not to assign myself any more credit than is due. I'm part of a really great group of people.



So I'd like to switch gears just a little bit and change the topic in thinking about where our profession is headed, and what you think that means for PA education. You know, we have a number of things happening in our profession right now with you know, the the topic of the doctoral degree being at the forefront. And you know, certainly the way PA is practice, with the APS OTP initiative, I think we're at the at a crossroads where we could see our profession changing in a not insignificant way in the next years to come. So talk a little bit about that, and maybe from GWS perspective, how are you thinking about that? And what does that mean for your program? And for your students and graduates of your program? Big question. You're both 501 DB



are pointing at each other. You know, actually, can I just say to begin, I actually think DD? And I actually have divergent views on this. To be completely honest, would you say DD?



Yeah, maybe? Um, I mean, I guess? Yeah, I think I think we do see it sort of from a different perspective, I sort of approach this from the frame, you know, especially when we think about OTP. When I teach PA students, I am teaching them to be independent decision makers, and to, so that if they find themselves in a situation where they don't have the the team collaboration, or the supervising physician that they're prepared, and I think that comes from just what I sort of knew I was going to be potentially experiencing as a National Health Service Corps scholar, that I was maybe going to be, you know, I had no idea what to anticipate, I didn't know if I was going to be placed in a satellite clinic where I was the sole provider, and in the small town of this larger, you know, sort of health system, I had no idea and so, you know, I attacked my learning in that manner to when I was a student. And so when I became a PA educator, it just made logical sense to me to, you know, to train the future PDAs with, you know, all the, you know, clinical decision making and clinical reasoning and, and, you know, experience and knowledge that we could possibly shove at them. And just also teaching them how to be more self directed lifelong learners in general, and to seek out being able to ask questions and to MIT and to be able to self assess their abilities and their competencies. Well, and so I like sort of the direction that we're going in as far as you know, TP and maybe towards a little bit more independent practice. But, and this might surprise you because I just said that I actually am not sort of a fan of the entry level doctorate program. I believe it could have some negative impacts on the profession in general, especially that the diversity of the profession, and the the essence of the profession and why the profession was even formed. I think that obtaining a doctoral degree is a personal decision based on you know, where you find yourself in your career in life and where you want to go. I don't think it's necessary to be a competent practicing physician assistant.



I think that where you come from on this has a lot to do with your experience. And, and that I think, is actually part of the source of the somewhat divergent views that Didi and I have on this. So Didi graduated and went out to a rural health clinic and have a lot of responsibility right off the bat, but but for and I'm not minimizing this, but four relatively typical complaints, right? Diabetes, hypertension, asthma, things like that. My first job was as the neuromuscular and neuro genetic diseases pa at Johns Hopkins Hospital. And I was taking within weeks of graduation, I was taking care of diseases, patients with diseases that I had never heard of, I was taking care of patients with diseases that the, my attending would say, Well, this is one of 13 people in the world that have ever been diagnosed with this disease. And these diseases were serious, life limiting diseases. And so it gave me a lot of respect for the training of a physician in a residency, the depth of that training, and a recognition that, you know, just if you that, you just, you need to really know what you don't know. And I think that's true for all PDAs don't get me wrong, but especially in a setting like this. And I also worked at the Johns Hopkins emergency department, which is a level one trauma center, and in a city that really has a lot of issues with violence. So again, people are coming in with gunshot wounds to the head, and chest and belly, or people are coming in with sepsis, and DKA. And six weeks out of PA school, I was not equipped to manage those patients on my own. My training my five week, emergency medicine, rotation had not trained me to care for those patients independently. So I, I'm a fan of the PA Dr model that we've worked with for a long time, which is where as my competence both in neurology and emergency medicine, increased, the direct supervision decreased. But that that was not a formal sort of legal thing, that that was an assessment of my skills and knowledge by the team with which I worked. I'm also not a fan of the doctoral degree as an entry level degree, I'm well known for this, for better or for worse, for advocating that if people pursue doctoral education, they should pursue something that's going to provide them a specific set of skills. So whether that's a doctoral degree in education, whether that's a doctoral degree in public health, whether it's a doctoral degree in health economics, or health policy or something, that that you go and that you obtain advanced level skills that will help you. And I think that some of the entry level doctoral degrees are so generalist that they don't actually provide a much greater skill set than people have coming out of PA school. And I think that's particularly reflected in some of the programs that are only like a year long, you know, an EDD or a PhD is five to seven years, DRP, ages, four to five years. And I just think you probably have more opportunities to gain specific skills with slightly longer training.



So that's been something that I've found interesting is that, you know, because the profession as a whole really hasn't had a collective conversation about really discussing what it means, you know, what a PA doctoral degree means, or what that would look like, or should it be focused in one specific way? Should there be some standardization and so, you know, that really speaks to what you were saying is that, you know, what do you think the opportunities and threats are of that, you know, to me, it seems like there is risk of some fractioning of our of our profession because, you know, we have entry level doctorates, and then, you know, we have the, you know, the other doctorates that you spoke of that, you know, maybe focused in a more, you know, more specific area or skill set. So, what do you think that means for our profession



going forward? I will say that, I think that it, what you need to pursue depends on what you want to do. From my perception, I think that a lot of these things entry level doctorates are a response to a perceived threat from the nurse practitioner profession that they just want to say be able to say like, Hi, I'm Dr. Smith, in the same way that the nurse practitioners say that the data is not clear to me that actually, there's a particular thread, the studies that have been published on that are all about PA, or NP perception. So they're like, I believe I didn't get this job because of this or that. But it's really hard to know why you didn't get a job, right? Like, did somebody just did you just not vibe with somebody? Or was it really that somebody just looked at paper? And I'm not saying it's not, I'm not saying it's untrue that PDAs without a doctoral degree are being denied? I'm saying, I don't think that we've ever looked at that in a systematic way that would really prove or disprove that assumption. And so maybe, you know, maybe entry level doctorate if, if nobody's ever going to hire another PA, again, maybe that's just what we have to do to compete with the PTs and the NPS and things like that. I think that there's a separate question about expertise. So I wonder about if you want to be a clinical leader, if you'd be better off getting an MBA, and being able to speak that language, right, or if you want to be an educator, if you'd be better off getting an EDD. And so I, I'm not entirely sure that these entry level doctorates are being marketed toward or being developed toward a specific outcome. And I think that's sort of the definition of doctoral education, right? Even the NPS, they're getting when they get a DNP, they're getting it in pediatrics, or oncology, they're getting it in an area of specialization, the idea of an undifferentiated doctorate is not actually a real thing, at least in academia. Right? You, by definition, have to focus on something. But do you think, Didi



I agree with everything that you said, you know, as far as going back to the topic of competition from nurse practitioners, you know, I can sort of give you sort of my perception from the lens of serving art as the chair of the PA Advisory Committee for the DC Board of Medicine, we have a lot of work to do, regarding advocacy for the profession, and education still regarding their profession, and our skill sets and our scope of practice and everything. And sometimes I think it's easy to think, Well, if we just sort of require that everybody's trained at a doctoral level, everything will work itself out. And that's not the case at all. There, you know, I have seen firsthand the concerns about pa practice and, and the sense of competition that we might even have in the health care, you know, in the in the health care system, even from I saw that very vividly in the Board of Medicine, some physicians just being very resistant to give us more opportunity to practice at our school, you know, at our level of training, because there was concerned that a doc would open up an urgent care and employ, you know, 20 PDAs, that were just it was like a factory of some sort. And so I feel like we our efforts should probably be more centered around, really proving what we can provide to the healthcare system and to the healthcare team, and building trust in our abilities. And I think that if we could do that, I think that we could get everything that we're looking for from the scope of practice, and in opening up some more doors for a little bit more independent practice in the future.



I think it's interesting to consider whether actually, walking into how introducing ourselves as doctor, right, especially in a clinical setting, might actually impair our quest for increased scope of practice, right? Because people are gonna say, I'm not gonna hire somebody who's going to introduce themselves as doctor when they're not a doctor. And I don't want to, I don't want a piece of that. So I think we, we, it's painted as this will move us forward, but I'm not entirely convinced that particularly with both organized medicine and with individual doctors, that it would necessarily be beneficial



thing. For my perspective, the doctorate does move us forward in terms of our knowledge base. And to your point, Tammy, I think it really does you become much more adept at a certain topic through the process of your dissertation in your research. I think the the issue that Didi brought up related to the physician community. We're having consternation about that is valid and, and challenging. Paula Phelps talked about this with our Idaho discussion. She's on the Idaho, the Idaho medical board. And so I'm not surprised to hear you said that, Didi, I think it's you, we've got these competing factors, right, we've got these, the increasing NBA isation of health systems and hospitals and clinics, who are looking at the bottom line. And there's this pressure in the US model of healthcare. To be profitable, you have to be profitable. Our students say they're excited to go out and make a six figure salary. But sometimes there's a disconnect as to what that means. And you have to produce revenue to support that salary. And, and yet, at the same time, you have the physician community that is, you know, we were our DMA was built on physician extension, in partnership in collaboration. And now we have some people in our profession that are that are unclear what OTP really means. I'm not even sure that our national groups understand what they're really saying. There seems to be a schism between different groups and what that means. And it's creating concern among the physician community, which I think is legitimate. So until we as a profession, have absolute certainty of what we what our DNA is going to be in the next 10 or 20 years, I think we're going to continue to fight this.



You know, interestingly, I've had people that are big advocates of OTP, who work clinically and are not educators that I work with clinically, come up to me and say, we, you, you people in education, you need to train them more, you need to do more, so that they can just be independent from the get go. And I was like, Well, how long do you think would be appropriate? Like three years, four years? Like, well, maybe? And I'm like, But then why wouldn't you just go to medical school? Right? And they don't have a good answer for that. There's a reason that it takes at minimum seven years for someone to be go from being a college student to being a full fledged doctor, right? We know that there's benefits to repetition and pattern recognition and increasing skill set over time. And, you know, I mean, I'm proud to be a PA, but my mother had Parkinson's disease, rheumatoid arthritis and coronary artery disease. And I will be completely honest with you, I did not want her primary care provider to be a newly graduated pa who was taking care of her on the back of a four or six week ambulatory medicine rotation. She is very, very complicated. And I would not trust a new graduate with that level of pathology.



Yeah, the average the average physician after residency has 15,000 hours of clinical experience, the average pa somewhere between 2020 500 That's a huge difference. Yeah, well, super interesting. I mean, we definitely haven't done this yet. We should probably invite you know, competing theorists on this show. So that we can kind of get get to like they do on the on the network channels. Right? You know, the point counterpoint.



Just gonna say that face the PA nation.



Oh, my gosh, Tammy, we got to do that. Both Steph and I were commenting in the chat box how interesting this has been, we always asked our guests if there's something that we didn't cover that you'd like to share. So we want to certainly leave that opportunity open to both of you.



Do you want to go back to it? And I know that you've done this and other podcast as well about what would you know, what would make an applicant really stand out for GW and I just want to say, and I think Tammy would agree with me that, in general, we're looking for someone who has who can demonstrate a commitment to service, leadership, advocacy, and who is resilient. And it's not shouldn't be surprising that that's what we're sort of looking for. Because when you look at our faculty and the leadership roles they've done and the advocacy work that they've done in the service that they've done, we're all we're looking for the future generation of PhDs and Pa educators. So I would say that if you're a well rounded person that has you know, all of those qualities, then you're a competitive applicant for the GW pray program, and we welcome your application.



Outstanding. Thank you for covering that duty. Tammy, anything from your perspective? No. Well, wonderful. Thank you both so much for taking the time with Stephen I to share everything about GW. It's been such an impressive institution for so long. We're talking Steph and I are doing a session on the closure of the first season. And there's so the six degrees of separation are really interesting through all the podcast sessions we've had. And of course, Jeff Heinrich has come up on previous podcasts. Howard Stryker, Jackie Barnett, there's just such Yeah, Susan Lila Sure. Jim Collie. So yeah, your original point to me about the tradition at GW is really well respected and just want to say thanks.



Thank you for having us. Yeah. Thank



you so much. It's been a pleasure.



But we want to thank our guest, Dr. Tambor, Midsumma, Dr. DT Herman for their candor and insights into the profession, what a great conversation. And we're just so thankful for the leadership and our profession. Tune in next week, as we speak with Mr. Steven Neal. He's a graduate of the University of Southern California. He's a National Health Service Corps scholar, and he is the Chief of Staff for the Navajo clinic at the chinley Arizona Indian Health Services. He has this unique leadership role as a PA that I think you'll enjoy, and a servant's heart to serve others in underserved communities.



Until next time, we wish you success with whatever path you are walking in life. And thank you for joining us. The purpose of this podcast is to provide news and information on the PA profession and is for informational purposes only. The views and opinions expressed in this podcast are those of the speakers and guests and do not necessarily reflect the official position or policy of the University of Arizona.

Debra Hermann,DHSc, MSHS/MPH, PA-CProfile Photo

Debra Hermann,DHSc, MSHS/MPH, PA-C

Debra A Herrmann, DHSc, MPH, PA-C
BS, Clinical Laboratory Sciences, Western Carolina University, 1996
MSHS and MPH, George Washington University, 2001
Certificate, Master Teacher and Leadership Development, GW, 2010
Doctor of Health Sciences, AT Still University, 2017
Debra (Dee Dee) Herrmann is an Assistant Professor and serves as faculty in the Department of Physician Assistant Studies and is the Director of the SMHS Center for Faculty Excellence.
Dr. Herrmann graduated from The George Washington University Physician Assistant Program in 2001. Immediately after graduation, as a National Health Service Corp Scholar, she practiced clinically in Outpatient Community Medicine in rural West Virginia. Since returning to the DMV area, she has practiced clinically in Emergency Medicine, Urgent Care, and Family Practice. In 2010, Dr. Herrmann completed the Master Teacher and Leadership Development program at the George Washington University and finished her Doctor of Health Science degree with an emphasis on adult education in December of 2017 at A. T. Still University.
At the GW PA Program, in addition to teaching and engaging in departmental/university service and scholarly pursuits, Dr. Herrmann has served as the Associate Director of the Didactic Curriculum, the Director of Clinical Education, and the Associate Program Director. She was appointed the Associate Director of Engagement for the SMHS Center for Faculty Excellence in 2018.
Dr. Herrmann was awarded the national Physician Assistant Educator Association Faculty Rising Star award for PA education in 2011. She served as the mayoral appointed chair to the PA Advisory Committee for the DC Board of Medicine from 2010 until 2016 and currently serves as an advisor to the committee on PA practice and regulations in the District of Columbia.
Her research interests include transition to professional practice, professional development and performance improvement, clinical reasoning, curriculum design, and educational innovations.

Tamara S. Ritsema PhD, MPH, PA-C/RProfile Photo

Tamara S. Ritsema PhD, MPH, PA-C/R

Tamara “Tami” Ritsema is an associate professor at the George Washington University PA program in Washington DC. She is also an adjunct senior lecturer at the St. George’s, University of London PA in London, England. She’s an alumna of the Emory University PA Program and holds a PhD in health workforce research. She has been very involved in assisting in the establishment of the PA profession in the United Kingdom. Her research interests include health workforce research and the development of the PA profession outside the United States. She is the editor-in-chief of “Physician Assistant: a guide to clinical practice”, a major textbook used in PA education.