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.
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
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
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.
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