This article discusses the evolution of the Physician Assistant (PA) role, from its infancy to its growth over the last 40 years, and what role the PA will continue to have in medicine
Physician Assistants and their Contributions to Medical Resident Training; Michael Goesch, MPAS, PA-C, Candice Dodge, MS, PA-C
Physician Assistant: Introduction and Definition
The Physician Assistant (PA) is a medical professional who works as part of a team with a physician. A PA is a graduate of an accredited PA educational program, who has become nationally certified and state-licensed to practice medicine with the supervision of a physician. PAs perform physical examinations, diagnose and treat illnesses, order and interpret lab tests, perform procedures, assist in surgery, provide patient education and counseling, and make rounds in hospitals and nursing homes. In the U.S., all 50 states and the District of Columbia allow PAs to practice and prescribe medications.
Physician Assistant school is modeled on the medical school curriculum, with a combination of classroom and clinical instruction. The average length of a PA education program is 27 months, in addition to the pre-requisite undergraduate degree. PA education includes instruction in core sciences: anatomy, physiology, biochemistry, pharmacology, physical diagnosis, pathophysiology, microbiology, clinical laboratory science, behavioral science and medical ethics. PAs also complete more than 2,000 hours of clinical rotations including family medicine, internal medicine, obstetrics and gynecology, pediatrics, general surgery, emergency medicine and psychiatry.1
Brief History of the Profession
The PA profession was created to improve and expand health care. In the mid-1960s, physicians and educators recognized that there was a shortage of primary-care physicians. To help with this need, Dr. Eugene A. Stead, Jr., of Duke University Medical Center, asserted that Navy Corpsman who had received considerable medical training during their military service would be excellent candidates for the first Physician Assistant Program in 1965. This program was the first of its kind, pioneered at Duke University with the first graduation on Oct 6th, 1967. Dr. Stead was familiar with the fast-track training of doctors during World War II, and used this as a template for the Physician Assistant curriculum.2 In the 1970s, the American Medical Association (AMA) recognized the PA profession, and the U.S. Congress passed the Rural Health Clinic Services Act, signed by President Jimmy E. Carter, to provide Medicare reimbursement for services provided by PAs in certified rural health clinics.2 The 1980s brought expanded acceptance of PAs with continued legislation for Medicare Coverage and the framework that would continue to educate providers, patients and the public on the abilities and roles of PAs. The 1990s saw more than 23,000 clinically practicing Physician Assistants in the United States, and by 1993 the Drug Enforcement Administration began to register PAs, who were now allowed to prescribe controlled substances. The U.S. Balanced Budget Act of 1997 recognized PAs as Medicare-covered providers in all settings at a uniform rate of payment. The U.S. Department of State agreed to hire PAs as Foreign Service health practitioners, initiating the expansion of PAs into foreign countries and international health systems. By 2007, all 50 U.S. states, the District of Columbia, and Guam allowed PAs to prescribe, and there were over 63,000 practicing PAs in the United States. PAs had gone from helping with a shortage in primary care to assisting doctors in every facet and specialty of medical care.
Physician Assistants in the Present
The PA profession has grown from one school in 1965 to over 170 schools with more than 90,000 nationally-certified PAs and just under 6,000 graduating every year. Physician Assistants are trained and allowed to work in every medical and surgical specialty. PAs work under the auspices of their supervising physician, and are limited only by state licensure, the institution and their supervising doctor. Many studies have been done showing that Physician Assistants have provided a quality of care that is comparable to their physician health care providers at a fraction of the salary cost. This ability for quality and cost effectiveness will become even more important as an ever-aging population and limited funds will put a continued strain on physicians and the services they are able to provide. The ability for PAs to work in all specialties, and even cross-train in multiple specialties, allows for care to be tailored to the specific needs of a supervising physician and patient population. For example, an urban-area nephrology practice may need PAs to assist with dialysis evaluation, follow-up care and routine physicals, while another rural town with only one doctor may need PA assistance to provide broad medical and emergency care to a town of 2500 residents. This ability of the PA to conform and thrive within the needs of the organization, hospital, town and even country will continue the expansion of the Physician Assistant role. As the U.S.need for PAs has grown the PA success has reached abroad. The Netherlands has a growing cohort of PAs, with five PA programs and approximately 400 PAs. India has a growing and promising community of approximately 300 PAs currently practicing. South Africa has developed a small number of programs that are similar to PA programs, called “Clinical Associates,” and in 2010, Saudi Arabia introduced its first “Assistant Physician” program.3
Effectiveness of Physician Assistants
Since the implementation of the regulations by the Accreditation Council for Graduate Medical Education (ACGME) limiting resident doctors’ workload to 80 hours, with stipulations on consecutive hours and time off in between shifts, U.S. academic hospitals have been forced to either abandon their resident programs and/or find a way to fill those physician hours. Many reports chose the word “substitution” in regards to using PAs as opposed to residents. Some doctors, and the authors of this article, feel that this is not an accurate term. Similar to residents, PAs are not independent practitioners. PAs have the potential to enhance the practice of physicians, not to replace them. Time utilization was one major focus of evaluation, with multiple studies showing that residents spend a large portion of time doing tasks that could be easily delegated to PAs.4,5,6 One study by Dresselhaus et al. concluded that only 45% of activities by residents were educational in nature, and that delegating activities such as documentation and administration to other staff would maintain the residents’ inpatient experience while reducing resident hours.4 These results were similar to findings by Knickman et al., which demonstrated the distribution of resident physicians’ time in a traditional model versus the contemporary model using a PA. Nearly 29% of resident time was spent gathering information, but with the assistance of a PA only 9% of their time was spent on this task. Interaction with patients, performing tests and transit time were types of activities that remained the same regardless of the presence of a PA.5 Time spent consulting and documenting dropped dramatically with the addition of a PA team member. These findings support that through utilization of a PA, resident physicians are in compliance with work hour restrictions and able to reach educational goals.
The introduction of PAs to supplement medical residency programs has been shown to have benefits that include (1) enhancing education for the residents, (2) providing a strong continuity of care, and (3) reducing overall salary costs for inpatient staffing.5 These findings were also consistent when discussing the implementation of PAs through different specialties. After a scheduled downsizing of one residency program, a study by Rosenfeld followed the integrations of PAs at New Britain General Hospital over 20 years and reviewed its goal of meeting in-house coverage, Residency Review Committee (RRC) and ACGME requirements.7 Russell reported that even with the residents and PAs sharing the surgical caseload, everyone was satisfied with their operating room experience and it was felt that having the PAs helped improve their overall clinical and educational experiences. In the study by Rosenfield et al., the integration of PAs into the newly reinstituted Surgery Resident Program allowed for improved continuity of care compared to rotating resident physicians, and prevented the need for cross-covering residents for family practice and internal medicine, increasing the residents’ time for educational activities and conferences.7 With PAs working in all medical sub-specialties, the benefits of integrating PAs into the medical residency programs, with continuity of care likely contributing to shorter stays, better outcomes and financial savings.6
Cost analysis for PAs in the inpatient setting is limited; most studies have focused on outpatient evaluation. The evaluation of PAs’ cost effectiveness on the inpatient side becomes difficult, as in any inpatient analysis, because tasks overlap and a team with multiple different designations provides the care. Cost effectiveness is dependent upon the degree of delegation and the effective utilization of the PA’s skill by the supervising physician. PAs contribute to improved educational experiences for resident physicians and medical students, improved time utilization for residents, and an increased amount of time spent on direct patient care and education.6
Studies have demonstrated the successful integration of PAs into academic hospital programs and all specialties. The success of this integration has been multifactorial in providing improved patient care, improved education for patients and residents, higher utilization and lower costs. As hospitals are continually required to do more with less, it is clear that employing PAs is an economic way to continue to provide excellent care to patients, while improving the education and training of residents.
The Future of Physician Assistants
The Bureau of Labor Statistics predicts that PAs will be the second-fastest-growing profession in the next decade, increasing from 74,800 in 2008 to 103,900 by 2018. The American Academy of Physician Assistants (AAPA) projects that in 2020, there will be between 137,000 and 173,000 certified PAs in the United States. As the medical community develops through this century with the expected advances in medical care, shortages of doctors, rising health care costs, increases in physician specialization and a large aging baby boomer population, it is clear there will continue to be a prominent role for Physician Assistants both in the U.S. and in other countries.
More and more hospitals and private practices are turning to PAs to help provide the care that their patients require. The need for more medical providers in the U.S. has been satisfied over the past several decades by large increases in PAs, while the numbers of residents and fellows has remained mostly unchanged since the 1990s. Physician Assistants are in the unique position to tailor their skills to a specific population need, whether it is in the clinic, the city or a rural area. The Physician Assistant’s practice and training will continue to be malleable and adaptable for whatever needs arise in the future. Throughout almost 50 years, Physician Assistants in the United States and elsewhere have helped fill the needs of the patients that they serve, and will continue to provide caring, affordable and quality medical care. Many clinical challenges face the health care systems and providers both in the U.S. and the rest of the world regarding how best to provide cost-effective quality medical care. It is clear that Physician Assistants are well entrenched as an excellent solution to many of these current issues.
About the Authors:
Michael Goesch, MPAS, PA-C graduated from Notre Dame College with Masters in Physician Assistant Studies in 2001. After graduation he started working in Emergency Medicine north of Boston for 8 years until moving to New Hampshire, where he continued in Emergency Medicine. He took his current position with Surgical Services with U.S. Department of Veterans Affairs in 2010, where he has the privilege of working with veterans and helping educate medical students and residents of Geisel School of Medicine at Dartmouth. He is finishing up his Fellowship in Wilderness Medicine, and teaches both Wilderness Medicine and Emergency Medicine and Surgery, passing his knowledge and experience on to fellow medical professionals.
Candice Dodge, MS, PA-C is a recent graduate of the Quinnipiac University Physician Assistant Program, where she received both a bachelor’s and master’s degree in Health Science. She currently works as a Physician Assistant with Surgical Services at the Department of Veterans Affairs Medical Center in White River Junction, Vermont, providing care to our veterans in Northern New England. Candice works with various surgical specialties including General, Vascular and Plastic Surgery and Urology.