Most Popular Physician Assistant Specialties

Research Objectives

The specialty distribution of the physician assistant (PA) profession has shifted away from primary care toward specialty care. Current information about PA specialty distribution and factors affecting specialty choice is needed to assess the adequacy and distribution of provider supply. This study describes PA specialty distribution trends, compares prevalence of PAs to physicians by specialty and correlates PA specialty prevalence with both PA and physician full-time salary.

Methodology

We used PA data on specialty and salary from the American Academy of PAs (AAPA) 2013 census, the only detailed source of national salary data available for PAs by specialty. Analyses will be repeated with National Commission on Certification of PAs (NCCPA) salary data to be released in January, 2015. PA specialty distribution from AAPA and NCCPA were compared. Physician 2012-13 specialty and salary data are from the AMA Masterfile and Medical Group Management Company. We used descriptive statistics, scatter plots, and linear regression (bivariate models and multivariate models with two independent variables) to examine the distribution and salaries of PAs and physicians in 24 specialties. Natural log transformations were used in the regression analyses due to skewed distributions.

Results

The proportion of PAs working in primary care was similar in AAPA and NCCPA data and decreased from 50% in 1997 to 30% in 2013 (AAPA). Substantial growth in PA proportions occurred in surgical and medical subspecialties. Physician to PA ratios were lowest in orthopedic surgery (2:1), neurosurgery (2:1) and cardiovascular surgery (3:1) and higher in family medicine (6:1). Regression models showed a higher prevalence of PAs in specialties with higher PA salary, higher physician salary, and higher physician:PA salary ratio (p<.05). These relationships were strongest in the surgical specialties, where physician salaries alone accounted for 80% of the variation in PA prevalence. Our study is limited by low PA survey response rates, although agreement between the AAPA and NCCPA surveys is reassuring. Our sample of only 24 specialties prohibited construction of more complex regression models.

Conclusions

PAs are moving toward subspecialty practice. Physicians in more lucrative specialties may have more incentive to hire PAs, and can offer PAs higher salaries. Our study suggests that demand for PAs, driven in part by financial benefits of PAs in high-paying surgical subspecialties, may be an important factor driving the trend toward specialization. To meet policy goals of increasing the proportion of PAs in primary care, greater understanding of these factors is needed.

 

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VA Hospital Guidelines for PAs and NPs

CONTINUUM OF REHABILITATION CARE

Rehabilitation occurs across a continuum at various levels of intensity and in different care settings. Veterans may have their rehabilitation provided in a variety of environments from acute inpatient hospitalization through a spectrum of inpatient and outpatient rehabilitation care settings, including CLCs and within the home, if medically appropriate. Regardless of the location, any designated inpatient rehabilitation unit must earn and maintain CARF Accreditation. NOTE: There is a waiver for smaller bed units, if approved by the National PM&RS Program Director.

The continuum of rehabilitation services is determined by the Veteran’s rehabilitative needs and not by the program’s location or designation. After a patient or CLC resident is identified as needing rehabilitation services, a designated and qualified rehabilitation specialist screens the patient or CLC resident. This person is called the Rehabilitation Point of Contact (RPOC).

Core Levels of Care. Core levels of care in the rehabilitation continuum include:

Acute Medical Rehabilitation Consultative Services. Hospitalized patients experiencing the onset of illness or injury may benefit from one or more rehabilitation therapies to assist in regaining physical and functional abilities. This is typically initiated by a consult to PM&RS.

An appropriate credentialed and privileged provider may initiate this consult to a physical medicine physician for a comprehensive medical assessment or to manage a specific condition, such as Polytrauma, TBI or amputation care, or to perform or recommend various modalities and therapy treatments. In most VA medical facilities, Licensed Independent Providers (LIP), Nurse Practitioners (NP) and Physician Assistants (PA) are able to initiate consults and make referrals for specific therapies such as OT, PT, KT, and RT specialists, if their approved Scope of Practice at the medical facility permits.

Specifically, PAs and NPs may provide and coordinate comprehensive PM&RS patient care services when authorized by an approved Scope of Practice. The Scope of Practice ensures that PAs practice medicine as agents of their supervising physicians with defined levels of autonomy.

PAs and NPs may order PM&RS consults and other specialty consults for assigned patients as the Scope of Practice permits.

These services are provided in central therapy clinics, satellite clinics, and at the bedside or in another environment (home, group home, assisted living facility, etc.) depending upon the needs of the patient.

Comprehensive Integrated Inpatient Rehabilitation Program (CIIRP) i.e., Inpatient Rehabilitation Bed Services.

CIIRP provides a patient-centered, coordinated, intensive program of multiple services delivered by an IDT that may include, but is not limited to: a rehabilitation physician, rehabilitation nursing, rehabilitation case management, OT, PT, SPT, KT, RT, social work, and May 2, 2014 VHA HANDBOOK 1170.03 19 psychology. The IDT supports and reinforces each patient’s individual plan of care 24 hours a day, 7 days a week (see VHA Handbook 1170.01, Accreditation of Veterans Health Administration Rehabilitation Programs).

CIIRP must meet high standards of care and earn accreditation from CARF. Regardless of the location, if an inpatient bed section’s function is designated as comprehensive inpatient rehabilitation it must be accredited by CARF.

The rehabilitation environment of care requires that rehabilitation beds are co-located in the same designated area, and that treatment areas provide opportunities for patients to interact with each other as part of the rehabilitation process. The physical location of inpatient rehabilitation beds varies. Rehabilitation bed units may be in their own designated area or may be located adjacent to acute medical services, such as neurology and general medicine. Rehabilitation beds may also be located in a designated area of the CLC.

The focus of the CIIRP is on meaningful functional improvement and successful community re-entry. Goals are identified in mobility, activities of daily living (ADL), instrumental activities of daily living (IADL), productive activity, and preparation for home and community. The treatment program has a specific timeframe and is goal-oriented with a focus on practical life-skills training. Treatment interventions are individualized and cost-effective, incorporating the Veteran, the Veteran’s family, and caregiver education and preparation for the Veteran’s transition back into the community. Patients usually remain in the CIIRP until goals are met, maximal functional improvement is achieved or it is determined that the needs of the patient would be better served within another continuum.

Each CIIRP program has admission criteria and an admission screening process. This level of care is appropriate for patients with one or more conditions requiring treatment by a rehabilitation team, at a level of intensity that can be provided more effectively and efficiently within an inpatient rehabilitation program. Patients are admitted from various sources, including the same facility, another VA medical facility, military treatment facilities (MTF), community medical facilities, and home. NOTE: Most programs offer short-stay evaluations, as needed, to determine ongoing care needs.

The Rehabilitation Continuum of Care Chart of Recommendations describes programming for specific rehabilitation services across the continuum of care. The Rehabilitation Continuum of Care Algorithm provides a decision tree for determining the most appropriate level of rehabilitation services for a patient with identified rehabilitation needs.

www.va.gov/vhapublications

Physician Assistant vs. Ambulance Nurse Study

Worldwide, there is an increasing demand for ambulance emergency medical services (EMS) in developed countries. The continued rise in utilization of emergency ambulances leads also to an increasing demand on the wider health care system, e.g. emergency departments (EDs), out-patient clinics, and acute hospitals. Potentially, it compromises access, quality, safety, costs, and outcomes of emergency care. Today, it is unclear what is the optimal care provision in hospitalize care, and how prehospital care can be effective; not only in diagnostics and treatment, but also in triaging patients for the right level of care, from a socioeconomically perspective.

In the Netherlands, prehospital emergency care is regularly provided by ambulance registered nurses (RN) as solo emergency care providers, and emergency medical teams, driver and RN, using a full size equipped ambulance. Recently, the position of the physician assistant (PA) has been introduced in ambulance EMS in the Netherlands. The PA works as solo emergency care provider. The aim of introducing a skill mix of PA and RN into ambulance EMS is twofold. First, EMS organisations want to assess and treat patients with emergency care complaints more adequately, as PAs work in the medical domain and RNs in the nursing domain. And second, the regional EMS organisations are exploring opportunities for individual growth and career perspectives of RNs through the PA education.

The education and competences of RNs and PAs differ. The RN has a mandatory 4 year bachelor education to become a registered nurse. Most RNs follow an education in intensive care, emergency care and/or anesthesiology, before they become an ambulance RN. Each of these supplementary nursing courses are combined with practice learning and take 18 up to 24 months of training, depending on a full or part time employment. Furthermore, the RN follows a prehospital ambulance emergency care education of 7 months, which is mainly focused on stabilization of vital signs, early interventions, and the prevention of relapse and adverse events. The PA, however, has a 4 year bachelor education in health care, followed by a 30 month medical training programme at a master level. A substantial part of the PA education is focused on medical/diagnostic competences and skills, such as examination of the patients’ organ tract systems .

The RN is registered as a nurse according to the Dutch Healthcare Performance Act, and has a functional autonomy within the framework of the national EMS standard. This standard covers 113 flowcharts with decision making strategies on diagnosis and treatment of signs and symptoms of 15 diagnosis groups e.g. airway, cardiology, internal medicine and trauma care. The professional autonomy of the PA in the Netherlands is comparable to the autonomy of a doctor of medicine without any medical specialisation . Furthermore, there are no specific national EMS standards for the PA.

The literature describes that the PA is increasingly involved in primary care teams and at the emergency department (ED) . However, we found no information on the role and function of the PA in ambulance EMS. Therefore, the aim of this study was to describe the patient care of the PA and RN as solo emergency care providers, based on differences in education. The hypothesis of this study was that there is no difference in outcome of care between the patients of PAs and RNs.

We performed a cross-sectional document study to provide insight in the patient care of the PA and RN, working as solo emergency care providers in EMS. On the basis of the study protocol, the Committee on Research Involving Human Subjects region Arnhem/Nijmegen waived the need for ethical approval (registration number 2016–2355).

Patients with urgency level A1 (arrival <15 min) and A2 (arrival <30 min) were enrolled in the study. We included all patients treated by two PAs in the inclusion period of two EMS organisations in the Netherlands: EMS Veiligheids- en Gezondheidsregio Gelderland-Midden (VGGM, n = 1) and EMS Veiligheidsregio Gelderland-Zuid (VRGZ, n = 1). For each EMS organisation we randomly selected, by syntax command in SPSS, an equal number of patients who were treated by RNs as solo emergency care providers: VGGM (n = 12 RNs) and VRGZ (n = 11 RNs). Due to a different employment date of the PAs in VRGZ and VGGM, the inclusion period for VRGZ was October 2010-December 2012 and for VGGM January 2013-March 2014. The inclusion number of PAs, RNs, and their patients was based on feasibility and not on a formal power analysis.

Data were drawn from the EMS Electronic Patient Records (EPR). Unique patient identifiers were excluded or made anonymous. We performed the data extraction according to a standardized protocol developed by PvG, SB, AdK, LS, see Table 1. Predefined data in the EPR were directly extracted. Other data were extracted from free text notes, interpreted, and categorised by two independent researchers (BvdA, PS). The first 100 cases were cross-checked. The latter data extraction was supervised and double-checked by a third researcher (AdK).

Key outcomes

Key outcome measures are shown in the data, together with the type of source, predefined field or free text notes, and the data processing protocol. First, we identified patient characteristics, level of urgency defined according to the Dutch EMS triage criteria and the initial complaints or conditions of the patient (trauma or non-trauma).

Second, we identified diagnostic measurements and interventions provided to the patient by PAs and RNs, according to their education and described in the national EMS standard. In the free text notes of the EPR, we identified the use of a systematic medical diagnostic approach, the SCEBS methodology (focused at Somatic complaints, Cognitions, Emotions, Behaviour, and Social functioning), according to the PA education. Furthermore, we examined whether PAs performed systematic physical examination of the organ tract systems, such as pulmonary tract, circulatory tract. Additionally, we extracted data on interventions provided by PAs and RNs based on their education. We classified these as described or not described in the national EMS standard. Finally, we examined the outcomes of patient care in terms of consultation of other medical specialists, referral pattern, length of treatment time on scene and follow-up contacts with the dispatch centre within 24 and 72 h after completion of treatment on scene.

Analytical methods

Data were analysed using descriptive statistics. In case of missing data only valid data were used in the descriptive statistics. The Tables show the total and the valid numbers. We used χ2 and Mann-Whitney U test to analyse for similarities and differences in outcome of patient care between PAs and RNs. Statistical significance was assumed at a level of P <0.05. All statistical analyses were carried out using Statistical Package for Social Sciences (SPSS version 22).

Results

In total 991 EMS runs were included in the study, 493 patients were treated by the PA (n = 2) and 498 patients were seen by the RN (n = 23). Nineteen runs were excluded from the study because they were not emergency A1 or A2 runs (n = 15), or they were registered twice (n = 4).

Patient characteristics, initial conditions and triage

The mean age of the patients was 50 years (PA: 52 (SD 25), n = 462; RN: 48 (SD 24), n = 496), and half of the patient sample was male (PA: 53 %, n = 251; RN: 51 %, n = 252). Two out of five initial conditions of the patients were trauma related (PA: 45 %, n = 218; RN: 40 %, n = 200), e.g. ‘injury due to fall’ (Table 2). Four patients were dead on the time of arrival at the scene (PA: n = 3; RN: n = 1). Most patients were triaged as ‘very urgent’ (PA: 70 %, n = 338; RN: 73 %, n = 361) and a smaller proportion as ‘urgent’ (PA: 30 %, n = 144; RN: 27 %, n = 136).

Initial complaints and conditions of patients treated by solo emergency physician assistants (PA, n = 2) and ambulance nurses (RN, n = 23)

Diagnostic measurements

The monitoring of vital signs in patients is presented in Table 3. In general, diagnostic measurements according to the national EMS standard were applied by RNs and by PAs. PAs used the SCEBS methodology (16 %, n = 77) and reported on exams of organ tract systems in one third of the EPRs (31 %, n = 155). These reports were not identified for the RNs.

Interventions

In general, we found limited information on applied interventions in conjunction with the national EMS protocol, except for pharmacological interventions. PAs provided medical advice to 48 % of their patients (n = 235). For RNs we found no reports on medical advice.

Outcome of emergency care

Table 5 shows the outcomes of emergency care. PAs completed their treatment on scene significantly more often than RNs. PAs referred 50 % (n = 245) of the patients to another health care professional, while RNs referred 73 % (n = 351) (χ2 = 52.9, df = 1, P <0.0001). In conjunction, we found that PAs consulted other health care professionals (GP, emergency physician, etc.) significantly more often compared to RNs (χ2 = 35.5, df = 1, P <0.0001), both consulted the GP most often. However, PAs and RNs referred more patients to the ED, and less patients to the GP. There was no significant difference between PAs and the RNs in length of treatment time on scene. After completion of the prehospital EMS care on scene, only a small proportion of patients contacted the dispatch centre again within 24 h (PA: 3 %, RN: 2 %) or within 72 h (PA: 5 %, RN: 4 %). This proportion was even smaller for the patients who were not referred to GP or ED and were only treated on scene by the PA or RN. Follow up contact after completion of prehospital EMS care showed no significant differences between PAs and RNs.

Discussion

The results of our study show that patients of PAs and RNs were comparable with respect to age, gender, and initial complaints/conditions. PAs and RNs reported diagnostic measurements according to the national EMS standard. In line with the medical education, PAs additionally used the SCEBS methodology (16 %), and a systematic physical exam of organ tract systems in a third of the patients. PAs and RNs provided similar interventions, as described in the national EMS standard. Additionally, the PA provided half of his patients with medical advice. Moreover, PAs showed significant differences in care outcome compared to the RN. PAs referred half of their patients to another physician, while RNs referred almost three out of four patients to a physician. The median treatment time of the PA and RN showed no variations. Finally, a small proportion of patients (4–5 %) called the dispatch centre within 72 h after completion of the emergency care on scene. Again, there were no significant differences between the PA and the RN.

Although it seems that PAs and RNs do not differ regarding their interventions according to the national EMS standard, it looks as if PAs thinks differently. PAs use a systematic physical exam more often, and consult other medical specialists more frequently. While RNs follow the national EMS standards and measure vital signs more often to get a complete picture of the patient. PAs are educated to use the SCEBS methodology, as a basis to decide on a preliminary diagnosis. Possibly the use of the SCEBS methodology makes additional measurement of vital signs superfluous. This might explain why PAs complete their treatment on scene more often, as they have more skills to perform a medical assessment on scene , compared to RNs. Studies in other fields of healthcare have suggested that the basic competences of the PA for a defined group of patients are comparable to the competences of a physician such as the GP , ED physician, and surgical and anaesthesiology residents . However, the PA needs a specific medical training, supervised by the GP, emergency physician or anaesthesiologist before these competences are gained. In our study the two PAs received previously an education as ambulance RN.

A previous Dutch study comparing solo emergency care provision of RNs with regular EMS treatment with a fully equipped ambulance team, showed that the solo emergency care provider was more likely to finish the treatment on scene. In our study the PA treats even more patients on scene, and seems to operate from a more general medical clinical perspective, comparable to the approach of the GP.

The question remains, whether the quality of care provided by PAs is (at least) equal to the care provided by RNs. Based on this study, we only have limited information on the actual outcome of care. As we found no differences between PAs and RNs in treatment time and repeating contacts of the patients, one could suggest that more consultation with other medical specialists and less referrals of the PA did not result in an increase of additional contacts with ambulance EMS within 72 h. However, data on extra ED visits of the same group of patients were lacking. Therefore, it remains partially unknown to what extent the patients of PAs more often needed emergency care at a later stage, or even worse, developed adverse events. Furthermore, insight in cost analysis of the care of PAs versus RNs needs to be explored.

Strengths and weaknesses

There are some limitations to this study. As we performed a retrospective document study, we did not observe the actual care provision of PAs and RNs. We based our findings on the EPR, and these data were not primarily gathered for research purposes. Therefore, the reliability of the results could be discussed. It is possible that not all emergency diagnostics and interventions, such as medical advice provided by the RN, e.g. ‘If the medication doesn’t result in adequate pain relief, please contact your general practitioner’, were documented in the EPR. Not all variables in our study concerned mandatory fields in the EPR. However, as the aim of our study was to provide insight in current patient care of PAs and RNs, we may argue that the report in the run sheets was not flattered in favour of research purposes.

The study period for the inclusion of patients of the PAs differed, as the PA of EMS VGGM finished his education 2 years later than the PA of EMS VRGZ. We chose to include the patients of the PAs at comparable levels of their experience, in order to provide a valid insight in the actual care provided to the patients.

The representativeness of results could be discussed, because we included patients of a limited number of two PAs. However, the actual employment of PAs in EMS in the Netherlands is relatively low (n = 12), so we included a 17 % sample for PAs. The yearly employment of RNs in 2014 was 2.180, which means a RN study sample of approximately 1 %. Therefore, we assume that the study provides a limited, though adequate insight in the patient care of the PA as solo emergency care provider in EMS.

Patient care and outcomes of PAs and RNs are likely to be influenced by patient characteristics, initial conditions of the patient, and the preliminary diagnosis in the prehospital phase of emergency treatment. It seems unlikely that the dispatch centre caused selection bias, as the assignment of patients to the PA or RN is based on the distance between the patient on scene and the available solo emergency care provider. The dispatch centre does not take the type of patient or complaint into account. Unfortunately, the information on initial conditions provided by the dispatch centre is not organized according to a validated classification system. Therefore, it is unknown whether similarities and differences in initial complaints/conditions are in fact definition problems, or concern actual similarities and differences in patient groups between PAs and RNs. Furthermore, EMS lacks a validated classification system on preliminary diagnosis. Therefore, we were not able to provide insight into preliminary medical diagnosis related to the outcome of emergency care provision, such as referral to GP and ED. Future studies should address this issue, and examine whether the results, that the PA finishes more treatment on scene, could be influenced by potential differences in initial conditions and preliminary diagnosis of the patients.

Future research

Despite the observation of these restrictions, the results of this first study on the role and function of the PA in prehospital EMS are very interesting and could be promising regarding optimal care provision in prehospital emergency care. As PAs provide less health care referrals, this could lead to the prevention of (unnecessary) admissions to the hospital, potentially to a decrease of diagnostic measurements and interventions in the ED, and furthermore, could result in a cost reduction . Areas for future research should be focused on external generalisation of study results, by scaling of the study design to a larger (national) level. Potential bias by differences in initial conditions and preliminary diagnosis of patients should be researched. Furthermore, the quality and outcome of emergency care provision on scene versus referral should be examined. Finally, cost analysis and cost effectiveness of the employment of the PA in ambulance EMS need to be further studied.

Conclusions

This study described the patient care of PAs and RNs as solo emergency care provider in EMS. In line with the nursing education RNs and PAs performed diagnostic measurements and interventions according to the national EMS standard. In line with the medical education, the PA additionally used the SCEBS methodology and a systematic physical exam of organ tract systems. In the outcome of care, the PA completed the treatment on scene significantly more often, while the median treatment time of the PA was comparable to that of the RN. Furthermore, the PA consulted significantly more often other medical specialists, and provided half of his patients with medical advice. Patients of PAs and RNs did not differ regarding additional follow up contacts with the dispatch centre within 72 h after care completion on scene. The role and function of the PA in prehospital EMS could be promising regarding optimal care provision in prehospital emergency care.

http://www.ncbi.nlm.nih.gov/pubmed/27357500

How Should We Train Pre-PA Students?

In light of the increasing demand for primary care services and the changing scope of health care, it is important to consider how the principles of primary care are taught in medical school. While the majority of schools have increased students’ exposure to primary care, they have not developed a standardized primary care curriculum for undergraduate medical education. In 2013, the authors convened a group of educators from primary care internal medicine, pediatrics, family medicine, and medicine-pediatrics, as well as five medical students to create a blueprint for a primary care curriculum that could be integrated into a longitudinal primary care experience spanning undergraduate medical education and delivered to all students regardless of their eventual career choice.The authors organized this blueprint into three domains: care management, specific areas of content expertise, and understanding the role of primary care in the health care system. Within each domain, they described specific curriculum content, including longitudinality, generalism, central responsibility for managing care, therapeutic alliance/communication, approach to acute and chronic care, wellness and prevention, mental and behavioral health, systems improvement, interprofessional training, and population health, as well as competencies that all medical students should attain by graduation.The proposed curriculum incorporates important core features of doctoring, which are often affirmed by all disciplines but owned by none. The authors argue that primary care educators are natural stewards of this curriculum content and can ensure that it complements and strengthens all aspects of undergraduate medical education.

http://www.ncbi.nlm.nih.gov/pubmed/27415445

Predicting scores for the PANCE PA certification exam

A link to the original article can be found here.

The focus of this study was determining
predictors of success on the
PANCE for students who attended the
Interservice Physician Assistant
Program (IPAP). The first U.S. Army
physician assistants graduated from the
Medical Field Service School physician
assistant program at Fort Sam Houston,
Texas, in 1973. The U.S. Air Force
started commissioning physician assistants
in 1978 while the U.S. Army did
not start commissioning until 1992.
The U.S. Army physician assistant program
was designated as the IPAP in
May 1996, and enrolled students from
all branches of the armed services as
well as the Bureau of Prisons, the State
Department, and The University ofTexas.

pancepredictions

As expected, the relationship
between the third trimester scores and
the PANCE scores revealed a statistically
significant result. For the third
trimester score; F (1,84) = 6.41, p < .05. The first trimester score; F (1,84) = 3.09, and the second trimester score; F (1,84) = 2.65, which are not significant. As a result, the second hypothesis was accepted based on significant correlation coefficients and F-ratio results. The PANCE study guide
proved to be the best predictor.
The third hypothesis was also tested
using the results from the correlation
matrix. The correlation coefficient of
.32 with p < .01 indicates a significant relationship although the correlation is not strong. Also, Phase II scores account for only 10% of the variance in the PANCE score. As a result, the third hypothesis is accepted, but demonstrates that clinical performance is not a strong predictor for the level of success on the PANCE.

Notes on the rapidly changing environment for the healthcare profession

The recent demand for medical professionals has catapulted the role of physician assistants into an ever escalating evolution. Lets take a look at some of the research which takes note of this.

Growth and change in the PA workforce

The physician assistant (PA) profession grew rapidly in the
1970s and 1990s. As acceptance of PAs in the health care
system increased, roles for PAs in specialty care took shape
and the scope of PA practice became more clearly defined.
This report describes key elements of change in the demography
and distribution of the PA population between 1967
and 2000, as well as the spread of PA training programs.
Individual-level data from the American Academy of Physician
Assistants, supplemented with county-level aggregate
data from the Area Resource File, were used to describe the
emergence of the PA profession between 1967 and 2000.
Data on 49,641 PAs who had completed training by 2000
were analyzed. More than half (52.4%) of PAs active in
2000 were women. PA participation in the rural workforce
remains high, with more than 18% of PAs practicing in rural
settings, compared with about 20% in 1980. Primary care
participation appears to have stabilized at about 47% among
active PAs for whom specialty is known. By 2000, 51.5% of
practicing PAs had been trained in the states where they
worked.

I find this interesting because the credentialing process for these professions had not changed in over three decades

The recent literature has moved on to discuss the role of PA’s influencing residents.

September 1, 2003, Vol 138, No. 9 >
< Previous ArticleNext Article >
Paper | September 01, 2003
Physician Assistant Influence on Surgery Residents FREE
Gregory P. Victorino, MD; Claude H. Organ, Jr, MD
[+] Author Affiliations
Arch Surg. 2003;138(9):971-976. doi:10.1001/archsurg.138.9.971. Text Size: A A A
Article
Figures
References
Comments
ABSTRACT
ABSTRACT | METHODS | RESULTS | COMMENT | CONCLUSIONS | ARTICLE INFORMATION | REFERENCES
Hypothesis We hypothesized that physician assistants (PAs) will decrease surgery resident work hours and improve resident work outlook.

Design Surgical resident survey.

Setting A county hospital in a university-based surgical residency program.

Participants Surgery residents who switched (or “rotated”) to the county hospital were polled monthly for 6 months after using PAs as team members on the surgical services.

Main Outcome Measures Resident work hours and work outlook.

Results Surgery resident hours were significantly decreased by the fourth, fifth, and sixth months after PAs joined the surgical services. Despite what these data on resident hours suggest, 6 (60%) of 10 residents believed that the PAs had no influence on the amount of time the residents spend in the hospital. Six (60%) of 10 residents thought the PAs decreased stress levels and 6 (60%) of 10 residents thought the PAs helped to improve morale.

Conclusions Physician assistants can have a positive influence on graduate surgical education programs. Physician assistants can help decrease surgery resident work hours and improve resident work outlook.

OVER THE PAST YEAR, many surgical educators have questioned whether the training of the general surgeon is optimal and many feel that graduate surgical education needs restructuring. The disappointing 2001 results resonated throughout surgical training programs across the country. After the 2001 match, there were initially 68 unfilled categorical first-level positions and 425 unfilled preliminary first-level positions. Senior medical student interest in general surgery hit an all-time low with only 6% of graduating medical students showing an interest in the discipline of surgery.1 In the past 9 years, the number of students applying to general surgery has decreased by 30%.2 The need for change is unquestioned and some have called for a “Halstedian 2” modification of graduate surgical education.3

The shift in perspective on surgical training is gaining widespread recognition. Graduate surgical education is a major topic of discussion at every surgical society meeting. Every month there seems to be another editorial addressing this issue and the ARCHIVES dedicated an issue to this subject. Many reasons have been given as to why a career in surgery has changed, including the significant debt incurred during medical school, the length of surgical training programs, poor work environments, decreasing reimbursement for surgical services, and lifestyle issues.4- 6

The Accreditation Council for Graduate Medical Education has released resident training guidelines that would modify many training programs and may or may not optimize the training of surgery residents. These include an 80-hour workweek and, maybe more importantly, a maximum work shift of 24 hours. The work that surgery residents perform should not be underestimated. If residency programs are to adhere to the Accreditation Council for Graduate Medical Education guidelines, then someone must make up the workload that would have been completed by the residents to ensure quality surgical care. Physician assistants (PAs) have been suggested as ideal candidates for the position.7- 9 Midlevel practitioners are able to reduce surgery house staff workload and improve patient care.10

Physician assistants have been in existence since the late 1960s and the idea of PAs working on a university teaching service is not new. Physician assistants have been used on trauma,11 orthopedic,12 pediatric,13 and thoracic and cardiovascular surgical services.14 Our department has spent several years working to acquire funding for PA positions on each surgical service at an urban county hospital. In light of recent events surrounding graduate surgical education, the approval for these positions could not have happened at a more opportune time. We hypothesized that PAs would decrease the work hours of surgery residents and improve the surgery residents’ work environment by decreasing their workload and work-associated stress, and thereby improving morale.

METHODS
ABSTRACT | METHODS | RESULTS | COMMENT | CONCLUSIONS | ARTICLE INFORMATION | REFERENCES
A general surgery resident survey was conducted from January 1, 2002, through June 30, 2002, at the county hospital in a university-based surgical residency program. General surgery residents while on service at the county hospital were polled monthly for 6 months after using PAs on the surgical services. The main outcome measures of the survey were resident work hours and work outlook.

There are typically 10 to 12 general surgery residents assigned to the 4 surgical services each month. Surgical rotations last for 1 to 2 months and residents rotate to the county hospital a few times each year. During the period of the survey, chief residents took night call from home on alternating nights, junior house staff took in-house call every third to fourth night, and trauma team members took in-house call every other day.

In the first week of January, 1 PA was assigned to each surgical service. The PAs were fully incorporated into the surgical team and functioned at the level of a postgraduate year 1 or postgraduate year 2 resident. The PAs are under the direct supervision of the chief resident or attending staff. Each PA worked 4 ten-hour shifts per week, usually 7 AM to 5 PM on Mondays, Tuesdays, Wednesdays, and Fridays. Thursdays are set aside for teaching conferences. The PAs switch (or “rotate”) between services every 3 months. Rotating the PAs provides a varied work experience and prevents the PAs from taking over a service. This rotation occurs on the 15th of each month to provide continuity of care because residents switch services on the first of the month.

The survey asked the following questions: (1) How many hours per week did you spend in the hospital? (2) With the PAs now on your service: (a) Is your workload decreased? (b) Do you feel less stressed at work? (c) Has your morale improved? (d) Do you spend less time in the hospital?

A total of 68 questionnaires were distributed to the surgery residents over the 6-month study period. Of these, 61 were completed and returned for a 91% response rate. The surgery residents’ replies were completely anonymous.

Resident work hours are listed in the text as mean (SE). Work hours were analyzed using repeated-measures analysis of variance; the differences between time points were analyzed using mean contrasts. Statistical significance was set at P<.05. RESULTS ABSTRACT | METHODS | RESULTS | COMMENT | CONCLUSIONS | ARTICLE INFORMATION | REFERENCES Surgical residents' weekly work hours per month are shown in Figure 1. Prior to the arrival of PAs, general surgery residents worked a mean of 102.2 (3.2) hours per week. Residents' weekly work hours slowly decreased over time and were significantly decreased by the fourth, fifth, and sixth month after PAs joined the various services. Work hours decreased to a mean of 89.0 (5.4) hours per week in April, 88.1 (4.2) hours per week in May, and 87.3 (2.8) hours per week in June. In 6 months, the presence of PAs on the surgical services enabled each surgery resident on average to reduce his or her workload by 15 hours per week. This equates to about a 1:1 ratio of resident work hour decrease to PA work hour completed. Figure 1. Surgical residents' weekly work hours per month. The mean (SE) baseline value of 102.2 hours per week (3.2) was obtained prior to the arrival of physician assistants. At the end of the study period, there was a decrease of 15 work hours per week per surgical resident. Asterisks indicate a significant decrease from the baseline value. Image not available. View Large | Save Figure | Download Slide (.ppt) The influence of PAs on resident workload is shown in Figure 2. This graph represents the percentage of residents who felt that the PA on their service helped to decrease their own workload. In January, 6 (67%) of the 9 residents felt that the PAs decreased their own workload. This increased to 100% in both May (12/12) and June (10/10). Figure 2. Influence of physician assistants on surgery residents' workload. This graph illustrates the surgery resident's perception of whether the physician assistant on his or her service helped to decrease his or her own workload. The y-axis represents the percentage of surgical residents who responded yes to the question. Image not available. View Large | Save Figure | Download Slide (.ppt) The influence of PAs on resident work-associated stress is shown in Figure 3. This graph represents the percentage of residents who observed less stress at work since the PAs arrived on their services. In January and February, 4 (44%) of 9 residents experienced less stress since the PAs arrived on their services. This increased slightly to 58% (7/12) in May and 60% (6/10) in June. Figure 3. Influence of physician assistants on surgery residents' work stress. This graph illustrates whether the surgery resident experienced less stress at work since the physician assistant started work. The y-axis represents the percentage of surgery residents who responded yes to the question. Image not available. View Large | Save Figure | Download Slide (.ppt) The influence of the PAs on the residents' perception of how much time they spent in the hospital is shown in Figure 4. This graph represents the percentage of residents who believed they were spending less time in the hospital since the PAs arrived on their services. In January, 44% of the residents believed they were spending less time in the hospital. This percentage was basically unchanged throughout the study period and was recorded at 40% (4/10) in June. Figure 4. Influence of the physician assistants on the surgery residents' perception of how much time the surgery resident spends in-house. This graph illustrates the surgery residents' perception of whether they were spending less time in the hospital since the physician assistant joined their service. The y-axis represents the percentage of surgery residents who responded yes to the question. Image not available. View Large | Save Figure | Download Slide (.ppt) The influence of PAs on surgery resident morale is shown in Figure 5. This graph represents the percentage of residents who experienced an improvement in morale after the PAs joined their services. In January, 44% of the residents thought that the PAs improved morale at work. This percentage increased slightly over the survey period and was recorded at 60% in June. Figure 5. Influence of physician assistants on surgery residents' morale. This graph illustrates if the surgery residents believed that having the physican assistant on their service improved their morale. The y-axis represents the percentage of surgery residents who responded yes to the question. Image not available. View Large | Save Figure | Download Slide (.ppt) COMMENT ABSTRACT | METHODS | RESULTS | COMMENT | CONCLUSIONS | ARTICLE INFORMATION | REFERENCES There has been significant discussion lately regarding the work environment of general surgery residents, resident work hours, and the need to reevaluate the training of general surgeons. Realizing the need to optimize the training of surgery residents, we petitioned our hospital administration for assistance in relieving some of the burden that surgery residents carry in caring for surgical patients at the county hospital. We proposed to the administration that PAs would be an efficient, cost-effective way to improve the surgical services. After years of dialogue with the hospital administration and numerous reports documenting the need for PAs, positions for surgical PAs were approved. The first PA training program in this country was started at Duke University, Durham, NC, in 1965. Since then, PAs have been used on trauma,11 orthopedic,12 pediatric,13 and thoracic and cardiovascular surgical services.14 Most of these services incorporated PAs owing to the pressures of downsizing of surgical residencies that were prevalent a decade or two ago. The problems facing surgery departments today are different; however, by bolstering the surgical workforce, PAs may help solve the problem now just as they did then. In 1979, a survey of chairmen of departments of surgery in hospitals with more than 400 beds revealed that PAs were working in one third of those departments. Two thirds of the chairmen felt the PAs improved surgical patient care and half thought that the PAs improved the quality of surgical residency training. They predicted an increase of 87% in the number of surgical PAs by 1985.15 Their prediction could not have had more foresight. The American Academy of Physician Assistants estimates there were 10 000 students enrolled in PA programs this past academic year and about 50 000 PAs in clinical practice at the beginning of 2002. The US Bureau of Labor Statistics projects that the number of PA jobs will increase by 53% between 2000 and 2010. This is more than 3 times the predicted increase in the total number of jobs available in the United States during the same period. The purpose of this study was to define the influence PAs have on surgery residents. More specifically, we wanted to know if having PAs as team members on surgical services would decrease resident work hours and if the presence of the PAs would improve the work environment of surgery residents. We hypothesized that the addition of PAs to the surgical teams would (1) decrease resident work hours, (2) decrease resident workload, (3) decrease work-associated stress, (4) decrease the time residents spent in the hospital, and (5) improve resident morale. The additional workforce provided by PAs enabled a significant decrease in the amount of hours the residents worked. This effect was not seen immediately since the decrease in work hours was not significant until the PAs had been on service for 4 months. The slow decrease in resident work hours over several months probably reflects the time necessary for a PA to learn the position and become an efficient member of the surgical team. Although the decrease from 102 to 87 hours per week represents an average decrease of 15 hours per week per resident, the 87 hours per week per resident does not adhere to the limits as set force by the Accreditation Council for Graduate Medical Education for resident work hours. For every hour of work put in by a single PA, there was 1 hour less work completed by a surgery resident. If we were to comply with the 80-hour workweek guideline by means of decreasing resident work hours through the hiring of additional PAs, 2 additional PAs would be needed. The costs of hiring each PA including benefits approaches $100 000 per year. This is funded by the hospital administration. Budgetary limitations will not support the employment of additional PAs. To comply with the resident work hour guidelines, we have made additional changes in the surgical services including an every fourth night call schedule for all residents. At the end of the study period, all residents noted that the PAs helped to decrease their workload. At the beginning of the study only 67% of the residents responded similarly. This may be owing to the fact that at the beginning of the study period PAs were new and residents spent time each day training the PAs. Although all residents at the end of the study period had a favorable reaction regarding the PAs' capacity to decrease their workload, this did not equate to a similar attitude toward the PAs' ability to decrease the time residents spent in the hospital. Sixty percent of the residents believed that PAs had no influence on their time spent in-house even after the PAs had been on the surgery service for 6 months. This opposes data we collected on resident hours showing a decrease of 15 hours per week per resident, an interesting finding that offers some insight on how surgery residents perceive the amount of time residents spend in the hospital. Residents may be unable to differentiate whether they are working 102 hours per week or 87 hours per week. What they do know is that they are working over twice a normal workweek and receiving no overtime pay. Financial concerns may be just 1 factor affecting the resident's stress level and morale. After the PAs were on service for 6 months, 60% of the residents experienced less stress at work. This also means that 40% of residents believed that the PAs did not influence their stress levels. Similarly, 60% of the residents thought that the addition of the PAs improved morale, while 40% did not. The constant pressure of life-and-death situations, job responsibilities, career, family obligations, and financial concerns can all lead to increased stress in the workplace and eventually may progress into morale problems. It is obvious that PAs and the potential they bring to decrease the workload of surgery residents and subsequently decrease resident work hours is not the only answer. Other potential stressors in the workplace need to be evaluated and addressed to optimize the learning experience of surgery residents. This study suffers from all the problems and biases inherent in surveys. The study period was short and included replies from residents switched to the county hospital for a short period. The decrease in resident work hours may also be attributed to increased resident experience and efficiency. Finally, data on stress and morale issues should be interpreted with caution owing to complexities involved with such issues. Although it is possible to apply statistical analysis to these data or stress and morale issues, we felt the complexities surrounding these issues would be less meaningful and, therefore, these analyses were not completed. Although our experience with surgical PAs had been a tremendously positive experience, we did make one mistake. When we started the interview process for the PA positions, we looked for candidates much as we would search for a surgery resident position. We thought the best candidates were smart, aggressive, and enthusiastic about surgery. It turns out that these personality traits result in an aggressive and enthusiastic desire to be in the operating room. This created some conflict with the junior house staff who rightfully deserve to be in the operating room. After 6 months, we had 2 PAs leave for positions in private practice with job descriptions containing more operative responsibilities and more exposure to surgical procedures. When recruiting new PAs, we now emphasize a need for a strong desire for patient care responsibilities on the wards and in the clinics and not as much in the operating room. More on this later -Aaron Perelman

What is the impace of adding a Physician Assistant to the workforce?

A study done by Harvard medical school in 2008 took a look at this question. You can find the entire article here.

The results of the study showed that patients admitted to the study service were younger, had lower comor-bidity scores, and were more likely to be admitted at night. After adjustment forthese and other factors, and for clustering by attending physician, total cost of care was marginally lower on the study service (adjusted costs 3.9% lower; 95%confidence interval [CI] 27.5% to 20.3%), but LOS was not significantly different(adjusted LOS 5.0% higher; 95% CI, 20.4% to 110%) as compared with housestaff ser vices. No difference was seen in inpatient mortality, ICU transfers, read-missions, or patient satisfaction.

The patients in the study consisted of a total of 5194 consecutive patients admitted to the general medicalservice from July 2005 to June 2006, including 992 patients on the physician as-sistant/hospitalist service and 4202 patients on a traditional house staff service.

-Aaron Perelman

The function of the current day Physician Assistant

Are physician assistants functioning like nurse practitioners, nursees, physicians, or some other model?

In the 1960s a shortage of primary care medical
providers in the United States, especially in the rural
and urban underserved communities, coincided with
the return of military servicemen who had delivered
medical care in Vietnam but were “unqualified.” One
solution was to train these men quickly and allow them
to work under the supervision of a physician. Dr
Eugene Stead, an advocate for a new breed of
healthcare worker, created the first training programme
for physician assistants in North Carolina in
1965. Four former Navy corpsmen enrolled. From this,
the profession has grown to over 45 000 practitioners,
55% of whom are women.6 This compares with
2 697 000 registered nurses (95% women), 196 000
nurse practitioners (data on proportion of women not
available),7 and 778 000 physicians (23% women).8 Half
of all physician assistants work in primary care; others
work in emergency care, surgery, orthopaedics, and
other specialties
Most applicants today are not former military personnel
but school leavers or health professionals who
have made an early decision to become physician
assistants. They have decided against medical school,
trading some future income and additional prestige for
lifestyle factors such as a more defined schedule and
fewer hours on call. Physician assistants are dependent
practitioners, always working under the supervision
(direct or by telephone) of a designated physician. Physicians
may delegate to physician assistants only those
medical duties that are within their scope of practice.