Finding purpose, satisfaction and energy is critical to those in the helping field. Our relationships at work can be critical to our happiness and success. I’m often a sounding board for those who become frustrated, tired and stressed over the relationship between themselves and their supervising physician. This Doctor Physician Assistant (PA) game is one that I see repeat itself over and over again in ANY institution. I began to think about the game in terms of power dynamics and how each is getting what they want. As a result, Doctor-PA relationship can be categorized into four types.
1. Collegial/complimentary
2. Parent/child
3. Transactional/temporary
4. Co-dependence/co-existing
Medicine has its own clear and hidden hierarchy between players. The physicians and PAs are not exempt from this power game. Recognition of expert knowledge, credentials, and skills place physicians at the top of the food chain, however, the PA profession is a challenging predator in the life cycle of power. The relationship and interactions between physician and PA are often carefully managed so as not to disrupt this dynamic. As a result, behaviors and habits begin to develop that define a style for the working relationship. To begin, the healthiest of MD-PA styles are the relationships exhibiting collegial and complimentary partnership.
Collegial/complimentary:
This working relationship allows a dynamic shifting of power and shared burden and success. There is a constant "give and take" that maintains balance within the natural hierarchy. Patient care becomes a shared experience and allows each individual to contribute their talents without threat and most importantly, to support one another’s success. This relationship is exactly as it sounds collegial and complimentary. This is the good one. The one to hold on to. One that should be celebrated and duplicated. You recognize this one. It’s the one that people envy. Unfortunately, there are three other common relationships I’m more likely to witness in the workplace.
Parent child.
Intuitively one understands the physician as the adult and the PA as the child. In game terms, the power belongs to the parent (physician) and the PA experiences the push and pull of a reward or punishment. This style of relationship the PA defers to the MD and often remains passive and struggles to become independent. Work is done to please and to avoid punishment rather than for self development or nurture of one’s own goals. The PA seeks safety and will often hold the MD in such high esteem and omnipotence that they lose sight of their own needs. Often seen with a less experienced PA and their MD, this is an immature relationship recognized by avoidance of difficult conversations, passive aggressive tendencies and reward punishment style behaviors. Some seasoned PAs may also fall into this style of relationship when paired with a highly critical physician or perfectionist. The physician looks at the relationship as a supervisor to the child (PA) and takes on the mindset that the PA is in need of strong influence/direction or supervision because of their inevitable fallacies as child. In turn, the PA may begin to act in a childish fashion when unable to verbalize their concerns. Deliberate avoidance of work, pouting or complaining to others about their working relationship rather than direct conversations with the physician. For many, if recognition of this parent child working style isn't modified resentment develops & disenchantment arrives. This bring us to the hallmarks of the next working relationship style.
Transactional/temporary
This style of relationship is recognizable by superficial pleasantries and a mindset of I do the work and I go home. Neither party has invested much interest in the individual person but rather is focused on the task at hand and the completion of the work. There is neither overt dislike nor over pleasure in day to day interactions. Little jabs here and there begin to bubble up over time and ultimately the relationship has a short life span as there is minimal growth, boredom and complacency that begins to undermine the work. Often seen when neither provider has not established purpose or meaning in their work. Burnout is quick to develop and players in the game are once again disenchanted. Fracture of the relationship is sure to come. Likely, the working relationship has a short lifespan.
The Co-dependent PA.
Social psychology field defines co-dependence as a mental health phenomenon commonly seen in families of alcoholics. Its often marked by its impact on identity and excessive responsibilities for others. I want to talk about co-dependency as a framework of interpersonal problems in the PA-MD relationship game. Broadly defined, we become so pre-occupied with others that we neglect who we are as a person and this leads to suffering and dysfunction. The PA will become so hyperfocused on the needs and behaviors of others that he/she identifies themselves as the fixer. Sadly, if we find ourselves in this workplace relationship style, we experience a sense of shame for ignoring our true self and values. I see many unhappy and exhausted PAs who engaged in this learned behavior of owning an unhealthy fixation on the needs of others or to please the surgeon. This plays out by attempting to take responsibility for their physician’s bad behaviors or absence of behavior. This is ultimately creating an addictive cycle of learned behavior that is driven by a need for safety and fulfillment. This game is common with both new and experienced PAs and to the casual observer can appear as a high functioning partnership. Looking closer, the physician is the one the benefitting much more from partnership and the PA finds themselves feeling trapped in a values struggle of helping professional and shame for feeling dissatisfied.
All four of these relationship styles can occur during your career and you can move through characteristics of each with the same provider. Recognizing where you are operating from on a daily basis can help act as a signpost to redirect you toward self fulfillment, self awareness and alignment of mutual goals. If personality and learned behaviors are not amendable to a collegial and complimentary partnership then packing up your things will be easier to recognize. The power dynamics in health care and specifically the MD-PA power game is a complex landscape. Our ego and our purpose are important behind the scene players that we should be looking for as influencers. Naming the style of relationship can help us recalibrate where we want to go and give us behaviors to adopt to get there faster. Awareness helps you navigate the game and begin leading in medicine
"Your present circumstances don’t determine where you can go; they merely determine where you start"-Nido Qubein
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