Acceptance/Collaboration with Health Professionals
Cost Effectiveness
Educational Programs and Curricula
Job Satisfaction
Legal Issues
Licensure and Certification
Marketplace Determinants
Minority PAs
Overview
Patient Acceptance
Practice Settings
Productivity and Task Delegation
Quality of Care
Reimbursement
Role Identity
Acceptance/Collaboration wtih Health Professionals
Caprio TV. Physician Practice in the Nursing Home: Collaboration with Nurse Practitioners and Physician Assistants. Annals of Long-Term Care. March 2006;14(3):17-24.
Increasing attention has been focused on the role of nurse practitioners (NPs) and physician assistants (PAs) to enhance the medical care provided to nursing home residents. This collaboration is a relevant and evolving influence on physician practice in the nursing home. The historical perspective, current research, and outcomes of NP and PA nursing home practice are discussed in this article in the context of physician partnership and in the establishment of future research initiatives.
Carrabba AS. CSMS is no longer an island. Connecticut Medicine. Jan 2008; 72(1):41.
Developing your Physician-PA Team. The Physician's Advisory. October 1999:7-8.
Dodds PR. Utilizing a medical chain of responsibility. [letter, commentary] Conn Med. Jan 2009; 73(1):39-40.
Easter DW. 32 ideas for achieving work-hours compliance. Jan. 2005. For American College of Surgeons. www.facs.org/education/rap/easter.html.
Frieden J. Patient demand spurs collaboration. Skin & Allergy News. Sept 1999; 30(9):1,4.
Leib, M. The physician view of non-physician providers. Arizona Medicine. Nov/Dec 2004:12.
Marriott P. The Physician-PA Team. Connecticut Medicine. Jan 2008; 72(1):52.
More doctors employ extenders, but are you happy with them? Physician's Advisory, Supplement. Aug. 2002; i-iv.
Pelz DM. Professional assistants no substitute for MDs. (Letter to the editor.) Ft. Lauderdale Sun-Sentinel. June 19, 2000 :14A.
Reines HD, et al. Integrating midlevel practitioners into a teaching service. Am. J. Surg. 2006;192:119-124.
Abstract: Meeting the educational needs and requirements of surgical resident physicians while achieving optimal patient care is a challenge for program directors. Midlevel practitioners (MLPs) were employed by a large community teaching hospital to augment the surgical teaching service, to improve continuity of patient care, and to provide resident physicians with greater flexibility to participate in classroom, operative, and clinical educational experiences. The MLPs were carefully integrated into the surgical program by creating the necessary buy-in, developing positive relationships, decreasing resistance, and reinforcing acceptance when demonstrated. MLPs function at the level of junior resident physicians and are active participants in the teaching and evaluation process. Structurally, MLPs receive their assignments from and report to the chief resident physician, but are ultimately responsible to the program director. Instituting the program required providing financial justification to administration and flexibility in meeting the diverse needs of the four teams. As a result, surgical resident physicians have been sufficiently freed from service activities to be able to capitalize on learning activities that range from surgeries to conferences. MLPs can be integrated into a surgical teaching program and become a positive force in the education of resident physicians.
Resnick AS, et al. How do surgical residents and non-physician practitioners play together in the sandbox? Current Surgery. Mar/Apr 2006;63(2):155-164.
Introduction: The reduction of resident work hours due to the 80-hour workweek has created pressure on academic health-care systems to find "replacement residents." At the authors' institution, a group of nurse practitioners (NPs) and physician assistants (PAs), collectively referred to as non-physician practitioners (NPPs), were hired as these reinforcements, such that the number of NPPs (56) was almost twice the number of clinical categorical surgery residents (37). An experienced leader with national credibility was hired to run the NPP program. On each service, the call system was changed to a night float system, whereby residents were pulled from traditional resident teams to serve as nighttime residents during the week. A total of 1-3 NPPs were hired for each team, but whether NPPs worked for the team as a whole, or were assigned to individual attendings, was left to the discretion of the division chiefs. One year after the start of this program, the authors wanted to study the effects it has had on both surgery resident education and NPP job satisfaction. Methods: An electronic, anonymous survey was conducted during a monthly surgery resident meeting, and out of 72 categorical and preliminary surgery residents, 50% submitted answers to 12 questions. A similar electronic survey was administered to all 56 NPPs, with 45% responding. Results: Overall, 63% of residents believed that lines of communication between surgery team members were clear, and 58% of residents and 71% of NPPs believed that attendings, residents, and NPPs worked together effectively. A total of 91% of residents believed that the addition of NPPs to the teams was positive overall, and 80% of NPPs were satisfied with their positions. Overall, 60% of residents and 50% of NPPs felt that educational goals were being met. Discussion: Implementation of the 80-hour workweek and introduction of NPs and PAs onto the inpatient surgical services has altered resident education at the authors' institution. Although overall most residents view the addition of NPPs to the clinical services as positive, there are concerns about the program. Although hired to fill the void left by decreasing labor hours of residents, NPPs do not necessarily have the same goals as surgery residents and there is confusion about how NPPs fit into the hierarchy of the traditional surgical team.
Sener SF. Integration of allied health personnel with surgical residents produces latticework of patient care delivery in an academic medical center. For American College of Surgeons. Jan. 2005. www.facs.org/education/rap/sener.html
Todd BA, Resnick A, Stuhlemmer R, Morris JB, Mullen J. Challenges of the 80-hour resident work rules: collaboration between surgeons and nonphysician practitioners. Surg Clin N Am. 84(2004);1573-1586.
Wells R. Letter to the Editor. Nebraska Medical Journal. December 1993; 78912):370.
White GL. Physicians, PAs and the Facts. Journal of the Mississippi State Medical Association. December 1997; 38(12):460.
White GL, Davis AM. Physician Assistants as Partners in Physician-Directed Care. Southern Medical Journal. October 1999; 92(10):956-960.
Abstract: 1998 marked the acceptance of Physician Assistants (PAs) as members in the Southern Medical Association. We review the history of the PA profession and, more importantly, the physician/PA relationship. We also provide an overview of PA education and certification requirements. Variations in state law regarding PA utilization, including the delegation of prescribing privileges, are discussed. Current American Medical Association guidelines regarding physician/PA practice are provided.
Access to Care
Mullan F, Frehywot S. Non-physician clinicians in 47 sub-Saharan African countries. Lancet. Dec 2007;370:2158-63.
Many countries have health-care providers who are not trained as physicians but who take on many of the diagnostic and clinical functions of medical doctors. We identified non-physician clinicians (NPCs) in 25 of 47 countries in sub-Saharan Africa, although their roles varied widely between countries. In nine countries, numbers of NPCs equaled or exceeded numbers of physicians. In general NPCs were trained with less cost than were physicians, and for only 3-4 years after secondary school. All NPCs did basic diagnosis and medical treatment, but some were trained in specialty activities such as caesarean section, ophthalmology, and anaesthesia. Many NPCs were recruited from rural and poor areas, and worked in these same regions. Low training costs, reduced training duration, and success in rural placements suggest that NPCs could have substantial roles in the scale-up of health workforces in sub-Saharan African countries, including for the planned expansion of HIV/AIDS prevention and treatment programmes.
Physician's office and outpatient pulse re2007. Patient Perspectives on American Health Care. 2007; Press Ganey Associates, Inc.
Silberman P, et al. Weathering the Practitioner Workforce Shortage. NC Jed J. May/June 2007; 68(3):159-68.
Strand J. et al. The roles and supply of nurse-midwives, nurse practitioners, and physician assistants in North Carolina. NC Med J. May/June 2007; 68(3):184-86.
Cost Effectiveness
Blessing JD. Is the physician assistant profession economical? Physician Assistant. April 2000:12,18.
Cohen MM, Wreford M., Barnes M, Voight P. Re-engineering surgical services in a community teaching hospital. Cost & Quality. April 1997: 48-58.
Abstract: The Grace Hospital Surgical Services redesign project began in December 1995 and concluded in November 1996. It was led by the Chief of Surgery, the Surgical/Anesthesia Services Director, and the Associate Director of Critical Care/Trauma. The project was undertaken in order to radically redesign the delivery of surgical services in the Detroit Medical Center (DMC) Northwest Region. it encompassed the Grace Hospital Main Operating Room (10 operating theatres) and Post-Anesthesia Recovery Unit, and a satellite Ambulatory Surgery Center in Southfield , Michigan . The four areas of focus were materials management, case scheduling, patient flow/staffing, and business planning. The guiding objectives of the project were to improve upon the quality of surgical services for patients and physicians, to substantially reduce costs, and to increase case volume.
Because the Grace Surgical Services redesign project was conducted in a markedly open, communicative, and inclusive fashion and drew participation from a broad range of medical professionals, support staff, and management, it created positive ripple effects across the institution by raising staff cost-consciousness, satisfaction, and morale. Other important accomplishments of the project included:
- Introduction of block scheduling in the ORs, which improved room utilization and turnaround efficiencies, and greatly smoothed the boarding process for physicians.
- Centralization of all surgical boarding, upgrading of computer equipment to implement "one call" surgery scheduling, and enlarging the capacity for archiving, managing and retrieving OR data.
- Installation of a 23-hour, overnight recovery unit and provision of physician assistants at the Ambulatory Surgery Center, opening the doors to an expanded number of surgical procedures, and enabling higher quality care for patients.
- Reduction of FTE positions by 27 percent at the Ambulatory Surgery Center . This yielded a total cost reduction of $1.5 million per annum in the annual budget of $10.3 million;
- Recruited 10 new podiatrists and increased the volume of cases brought to Northwest Region facilities by surgical specialists. This added 100 cases in 1996, and is projected to add 500 cases in 1997.
- A 14.5 percent reduction in the cost of operating the Surgical Services was achieved. This was accompanied by enhanced staff morale, physician satisfaction and a higher quality of patient care.
Delmar D. Physician Extenders Boost Efficiency. Family Physician. June 30, 1999: 58.
Grzybicki DM, Sullivan PJ, Oppy JM, Bethke AM, Raab SS. The economic benefit for family/general medicine practices employing physician assistants. Am Journal of Managed Care. July 2002;8(7):613-620.
Objective: To measure the economic benefit of a family/general medicine physician assistant (PA) practice.
Study Design: Qualitative description of a model PA practice in a family/general medicine practice office setting, and comparison of the financial productivity of a PA practice with that of a non-PA (physician-only) practice.
Methods: The study site was a family/general medicine practice office in southwestern Pennsylvania. The description of PA practice was obtained through direct observation and semistructured interviews during site visits in 1998. Comparison of site practice characteristics with published national statistics was performed to confirm the site's usefulness as a model practice. Data used for PA productivity analyses were obtained from site visits, interviews, office billing records, office appointment logs, and national organizations.
Results: The PA in the model practice had a same-task substitution ratio of 0.86 compared with the supervising physician. The PA was economically beneficial for the practice, with a compensation-top-production ratio of 0.36. Compared with a practice employing a full-time physician, the annual financial differential of a practice employing a full-time PA was $52,592. Sensitivity analyses illustrated the economic benefit of a PA practice in a variety of theoretical family/general medicine practice office settings.
Conclusions: Family/general medicine PAs are of significant economic benefit to practices that employ them.
Hooker RS. A cost analysis of physician assistants in primary care. JAAPA. Nov 2002; 15(11):39-50.
Abstract: Acute medical conditions commonly seen by physician assistants (PAs) or physicians were assigned costs for all resources used to treat an episode of illness. Included in the analysis were data on the provider of record for the episode, patient characteristics, health status, diagnosis, treatment, referrals, medication, imaging, laboratory studies, and return visits. In every medical condition managed by PAs, the total episode cost was less than a similar episode managed by a physician, regardless of patient age, gender, health status, and department. Few differences emerged in the use of resources and the rate of return visits for a diagnosis between physicians and PAs. In this setting PAs appear to be cost-effective from an employment standpoint.
Hooker RS. The economic basis of physician assistant practice. Physician Assistant. April 2000:51-71.
Abstract: The performance of physician assistants (PAs) has been of interest to the health workforce and policy analysts since the introduction of the PA profession in the mid-1960s. Most of the economic research has focused on cost-effectiveness, using physicians or nurse practitioners for comparison. A review of the literature finds that a PA can safely assume at least 83% of all primary care visits without direct physician supervision. Using the substitution ratio, a PA can perform at least 75% of a physician's tasks at a cost of 44% of the physician's salary, based on 1999 average primary care salaries for physicians and PAs. Cost-benefit analyses of PA-delivered primary care suggest the use of resources is less than physicians under comparable circumstances. The cost of training a PA is approximately one fifth that of an allopathic physician. Because of the difference in length of education between PAs and physicians, the PA provides 5 years of patient care valued at $380,000 (1999 dollars) before the physician completes a primary care residency and enters health care practice. These factors, plus the compensation-to-production ratio, establish the PA as one of the most cost-effective health care clinicians to employ.
Kaissi Am, Kralewski J, Dowd B. Financial and Organizational Factors Affecting the Employment of Nurse Practitioners and Physician Assistants in Medical Group Practices. J Ambulatory Care Manage. July-Sept. 2003, 26(3): 209-216.
Summary: This study examines the financial and organizational factors that are associated with the employment of nurse practitioners (NPs) and physician assistants (PAs) in medical group practices. The source of the data is a survey of 128 medical group practices in Minnesota . The findings suggest that the employment of NPs and PAs and their ratios to primary care physicians (PCPs) in practices that employ them are influenced by the organizational characteristics of the group practice but not by the degree of financial risk sharing for patient care,. Although neither the number of years of experience in financial risk sharing nor more revenue from capitation payment contracts were related to employment of these midlevel practitioners (MLPs), large practices, those located in rural locations, not-for-profit practices, and those that scored low on cohesive cultural traits were more likely to employ MLPs. The data provide insights into the market for MLPs and the potential for these clinicians in the future health care system. As medical group practices become larger and have more organizational capacity, they can likely be expected to increase the employment of MLPs and integrate them into their organizations.
King A. Practices see more patients faster, free up physicians for more consults - thanks to NPPs. Non-Physician Practitioner News. Feb 2001;1-4.
Compares salary ranges for PAs and NPs
Mid-level providers pull twice their weight. The Physician's Advisory. Jan. 2000:6.
Morgan, PA, et al. Impact of PA care on office visit resource use in the US. Health Services Research. Oct 2008; 43:(5) Part II: 1906-1922.
Objective: To investigate whether the use of physician assistants (PAs) as providers for a substantive portion of a patient’s office-based visits affects office visit resource use. Data Source: Medical Expenditure Panel Survey (MEPS) Household Component data from 1996 to 2004. Study Design: This retrospective cohort study compares the number of office-based visits per year between adults for whom PAs provided ≥ 30 percent of visits and adults cared for by physicians only. Data Collection/Extraction Methods: The Agency for Healthcare Research and Quality collects MEPS data using methods designed to produce data representative of the U.S. noninstitutionalized civilian population. Negative binomial regression was used to compare the number of visits per year between persons with and without PA care, adjusted for demographic, geographic, and socioeconomic factors; insurance status; health status; and medical condition. Principal Findings: After case-mix adjustment, patients for whom PAs provided a substantive portion of care used about 16 percent fewer office-based visits per year than patients cared for by physicians only. This difference in the use of office-based visits was not offset by increased office visit resource use in other settings. Conclusions: Results indicate that the inclusion of PAs in the U.S. provider mix does not affect overall office visit resource use.
Page L. Midlevels: Boost or Burden? Medical Economics. Sept. 2008;26-29.
Palazzolo JD, Riner RN. Help in the middle. J Invasive Cardiology. July 2001;13(7):558-561.
Physician Extenders - Still a Solid Investment. Physician's Advisory. May 1999;6-7.
Regan DM. Physician extenders can expand access cost-effectively. MGMA Connexion. March 2002:48-55.
Roblin DW, Howard DH, Becker ER, Adams EK, Roberts MH. Use of Midlevel practitioners to achieve labor cost savings in the primary care practice of an MCO. Health Services Research. June 2004; 39:(3):607-625.
Objective: To estimate the savings in labor costs per primary care visit that might be realized from increased use of physician assistants (PAs) and nurse practitioners (NPs) in the primary care practices of a managed care organization (MCO). Study Setting/Data Sources: Twenty-six capitated primary care practices of a group model MCO. Data on approximately two million visits provided by 206 practitioners were extracted from computerized visit records for 1997-2000. Computerized payroll ledgers were the source of annual labor costs per practice from 1997-2000. Study Design: Likelihood of a visit attended by a PA/NP versus MD was modeled using logistic regression, with practice fixed effects, by department (adult medicine, pediatrics) and year. Parameter estimates and practice fixed effects from these regressions were used to predict the proportion of PA/NP visits per practice per year given a standard case mix. Least squares regressions, with practice fixed effects, were used to estimate the association of this standardized predicted proportion of PA/NP visits with average annual practitioner and total labor costs per visit, controlling for other practice characteristics. Results: On average, PAs/NPs attended one in three adult medicine visits and one in five pediatric medicine visits. Likelihood of a PA/NP visit was significantly higher than average among patients presenting with minor acute illness (e.g., acute pharyngitis). In adult medicine, likelihood of a PA/NP visit was lower than average among older patients. Practitioner labor costs per visit and total labor costs per visit were lower (p < .01 and p= .08, respectively) among practices withi greater us of PAs/NPs, standardized for case mix. Conclusions: Primary care practices that used more PAs/NPs in care delivery realized lower practitioner labor costs per visit than practices that used less. Future research should investigate the cost savings and cost-effectiveness potential of delivery designs that change staffing mix and division of labor among clinical disciplines.
The Man Who Would Save Health Care. Forbes.com Dec. 11, 2000.
Time to Consider Using PAs and NPs. Medical Office Mgmt. May/June 2001; www.pahcom.com/v143/v143_pa_np_.htm.
Weiss GG. PAs and NPs: How they boost practice earnings. Medical Economics. Feb. 16, 2007.
Educational Programs and Curricula
Abrass CK, Ballweg R, Gilshannon M, Coombs JB. A process for reducing workload and enhancing residents' education at an academic medical center. Academic Medicine. August 2001; 76(8):798-805.
Abstract: Academic medical centers are under increasing pressure to find alternatives to residents for the provision of patient care and to expand and improve the educational opportunities for residents. To address these concerns, the authors performed a study of the medical wards at Harborview Medical Center , a county-owned medical center managed by the University of Washington School of Medicine. Admitting diagnoses, provider names, and billings were obtained from professional practice plan billing records. Based on the distribu5tion of admitting diagnoses, a subset of patients was identified that could be removed from routine care by residents and could instead be cared for by non-physician providers (i.e., physician assistants and nurse practitioners) using clinical pathways. The cohort was large enough to reduce the number of patients per resident to within national accreditation guidelines, and to provide faculty with more time available for teaching. The authors summarize the approach used to identify the new model for care delivery indicated above and the plans made to implement that model and to analyze its impact on the quality of patient care, hospital costs, residents' education, and the process of implementing change. The authors conclude that solutions to the problems of workload and education that they confronted will vary by department and hospital setting. Yet a systematic approach to discovering solutions, such as they present, can be adapted to any setting.
Asprey D, Helms L. A description of physician assistant postgraduate residency training: the director's perspective. Perspective on Physician Assistant Education . 1999;10(3):124-131.
Purpose: Postgraduate residency training is an optional form of education that has existed within the physician assistant profession since 1971. Despite existing for nearly three decades, there are no comprehensive data regarding the residency programs. At the time this study was conducted, 17 residency programs existed dispersed among 10 different states. This study was undertaken with the purpose of characterizing physician assistant residency training in the United States. Methods: This study utilizes a non-experimental, descriptive research design and reports and describes various characteristics, activities and opinions regarding physician assistant, postgraduate residency training from the residency program director's perspective. Data were collected utilizing a survey instrument which was reviewed by a select group of residency directors to determine the suitability of the survey design and clarity of the questions for the resident directors. Standard procedures for gaining approval and clearance for studies involving human subjects were followed. Sixteen (94%) of the 17 residency directors responded. Data were entered into a relational database. Descriptive statistical analyses utilized a standard statistical software package. Results: Results from the study are reported for the survey data collected from PA program residency directors. Data are categorized as follows: general characteristics of residency programs, program admissions, program finances, compensation and personnel, program curriculum, and program director opinions regarding PA residency education. Conclusions: Data provided in this study help to describe and characterize PA residency education as it exists today. PA postgraduate residency education provides an important educational vehicle for training graduate physician assistants in specialty care. Important differences exist between the internship and academic model programs. Some residency programs do not maintain records systematically. Additional documentation by the residency programs is needed to describe program functions and provide evidence of the value and outcomes associated with postgraduate PA education.
Asprey D, Helms L. A description of physician assistant postgraduate residency training: the resident's perspective. Perspective on Physician Assistant Education. 2000;11(2):79-86.
Purpose: Postgraduate residency training is an optional form of education that has existed within the physician assistant profession since 1971. Despite almost three decades of experience, there are no comprehensive data regarding PA residents' opinions about their residency training. At the time of this study, there were 17 residency programs in 10 different states. This study was undertaken to characterize PA residency training in the United States from the perspective of participants. Methods: This study utilizes a non-experimental, descriptive research design to describe residents' perspectives of various characteristics, activities and opinions regarding PA postgraduate residency training. Data were collected from a survey instrument reviewed by a select group of residency directors for design and clarity. Standard procedures for gaining approval and clearance for studies involving human subjects were followed. Forty-six (59%) of the 78 enrolled residents responded. Data were entered into a relational database. Descriptive statistical analyses utilized a standard statistical software package. Results: Results from the survey data collected from the PA residents are reported. Data are categorized as follows: resident demographic information, entry-level PA program information, pre-residency program information, residency program information, residency curriculum data, residents' perceptions of changes in knowledge and skills and residents' opinions regarding residency. Conclusions: PA postgraduate residency education provides an important educational vehicle for training graduate PAs in specialty care. A substantial proportion of residents proceed directly from entry-level to postgraduate training. Residents report satisfaction with their programs generally and specifically in terms of knowledge and skills acquired. More information comparing the differences between academic and internship models of residency education is needed as is consideration of greater standardization in program record-keeping and support for research into the longitudinal outcomes associated with postgraduate education.
Ballweg R, Wick KH. Decentralized didactic training for physician assistants: academic performances across training sites. J. Allied Health. Winter 1999;28(4):220-225.
Abstract: Decentralized training for the didactic portion of allied health programs has been assessed for its ability to increase the likelihood that graduates will practice in underserved areas. The question still remains whether these distant sites provide an education that is comparable to that offered at the main campuses. Exams and final grades for all classes over the course of five years at MEDEX Northwest in Seattle were compared to determine whether there was any major discrepancy between the main training location and the decentralized sites. With the exception of three individual cases, overall academic performance in all training sites were comparable. This suggests that programs employing some of the curricular and administrative controls in place at MEDEX Northwest can achieve a parity in education across their various training sites.
Bowlin SD, Gugelchuk GM. The Use of Retention Strategies in Physician Assistant Programs to Retain and Graduate Minority Students. Perspective on Physician Assistant Education. Winter 2000; 11(1):7-11.
Physician assistant program directors across the country were interviewed about their use of retention strategies to retain and graduate minority PA students. Purpose: To determine the extent to which minority retention strategies are utilized in physician assistant programs and to describe the types of strategies used to retain and graduate minority students. The final purpose was to determine if there was a link between the use of particular strategies and the rate of minority student retention. Method: A descriptive study was conducted in 1997 via telephone interviews with the directors or director's designees from the 83 accredited physician assistant programs in the U.S. Results: 79 of 83 PA programs utilized retention strategies of some type. Of the 42 programs that also enrolled minority students, all employed a combination of tutoring, mentoring, and academic counseling, plus at least one additional strategy: prematriculation programs, special recruitment and retention focus programs, or early detection strategies. Minority retention success rates are dependent on the strategies employed, and program commitment to minority retention in general appears to influence the success that a program will have with any particular strategy. Conclusions: Student retention strategies are widely used by PA programs, and the strategies used appear to be successful in retaining minority PA students. However, success in the employment of these strategies appears to involve program commitment to retaining students in the context of an active learning partnership.
Cawley JF. Inappropriate appropriations. Clinician News. Oct 2001; 9.
Cawley JF. Physician Assistants and Title VII Support. Academic Medicine. Nov 2008; 83(11):1049-1056.
Abstract: Federal support through Title VII, Section 747 has played an important role in promoting the use of physician assistants (PAs) in primary care and in the growth and institutionalization of PA educational programs in the United States. Federal workforce policy approaches include PAs in strategies to (1) increase the supply of generalist providers, (2) better balance the distribution of providers to rural and medical underserved areas, and (3) improve the diversity of the health workforce. Evidence from several decades shows that, likely because of Title VII program incentives, PAs have met expectations in terms of practicing in primary care specialties and serving in rural and medically underserved areas. Yet, increasingly, market forces and decreasing federal support for Title VII are affecting these trends, with PAs, like physicians, being drawn to specialty practices.
There is considerable use of PAs in all practice settings in U.S. medicine. For several decades, PA training programs have demonstrated that they are efficient means of preparing clinicians who provide considerable benefit to society in return for a modest public investment. At the present time, when the climate seems not to favor public subsidy of health professions education, it may be wise for policy makers to consider strategies that address the long-term needs of the health care workforce and the public for primary care clinicians.
Diekema DJ, et al. Motivation for hepatitis B vaccine acceptance among medical and physician assistant students. J Gen Intern Med. Jan 1995;10:1-6.
Purpose: To evaluate the acceptance rate and motivation for acceptance of hepatitis B virus (HBV) vaccine among preclinical medical and physician assistant (PA) students in comparison with similar data obtained from resident and staff physicians. Methods: A cross-sectional survey of all second-year medical and PA students (n = 170) at the University of Iowa College of Medicine was conducted in spring 1992, requesting demographic data, preventive health measure use, and reasons for HBV vaccine acceptance. Responses were compared with data obtained from resident and staff physicians during a concurrent hospital-wide survey. Rates of vaccine acceptance and use of other preventive health measures were compared across the physician groups. Factor analysis was performed to examine reasons for vaccine acceptance among the students. Results: The questionnaire was completed by 162 of the 170 students (95%). Nearly all (99%) of the eligible students had received at least one dose of the HBV vaccine. Vaccine acceptance rates were significantly higher among the students than among either the resident or the staff physicians (p = 0.003, p < 0.0001, respectively). Influenza vaccine acceptance and seat belt use were significantly higher among the resident and staff physicians than they were among the students. The students attributed their high HBV vaccine acceptance rate to the recommendations of authority figures. Threat of illness and issues of vaccine safety and efficacy were relatively unimportant among the students, thought the residents and staff physicians reported threat of illness to be an important motivator for vaccination. Conclusions: Excellent HBV vaccine acceptance rates may be achieved among preclinical medical and PA students. Recommendations of authority figures are important motivators for HBV vaccine acceptance among students.
Diekema DJ, et al. Universal precautions training of preclinical students: impact on knowledge, attitudes, and compliance. Preventive Medicine. 1995;24:580-585.
Background: Little information exists regarding the impact of universal precautions training programs on preclinical students' knowledge, attitudes, and behavior. Methods: We developed, implemented, and assessed an educational program in universal precautions for 2nd-year medical and preclinical physician assistant students. Students (n = 170) completed pre- and post-training questionnaires to assess universal precautions knowledge and to evaluate attitudes about their perceived risk for bloodborne pathogen infection, the importance of universal precautions procedures, and their willingness to provide care for human immunodeficiency virus (HIV)-positive or acquired immune deficiency syndrome (AIDS) patients. Phlebotomy, intravenous catheter insertion, and arterial blood gas sampling techniques were demonstrated, practiced, and evaluated during practical training sessions. Outcome measures included changes in pre- and post-training knowledge scores and attitudes, as well as observed compliance with universal precautions during practical training. Results: Universal precautions knowledge scores increased significantly after training (P < 0.0001). Personal assessments of the risk of developing HIV due to patient care significantly decreased (P < 0.0001) and willingness to provide care for AIDS patients increased (P = 0.004) following training. Importantly, students reported that high expected rates of contact with HIV-positive and other patient groups would not significantly affect their specialty choice. Observed compliance with universal precautions procedures during practical training ranged from 95 to 99% for glove use, 76 to 77% for direct sharps disposal without needle recapping, and 56 to 78% for handwashing after glove removal during phlebotomy and intravenous catheter insertion. Conclusions: This program is effective in increasing students' knowledge of universal precautions. Training favorably affects students' willingness to care for HIV-positive patients and their assess risk of developing occupational bloodborne infection.
Evans TC, et al. Academic degrees and clinical practice characteristics: the University of Washington physician assistant program: 1969-2000. J. Rural Health. Summer 2006;22(3):212-219.
Abstract: Context: The physician assistant profession has been moving toward requiring master's degrees for new practitioners, but some argue this could change the face of the discipline. Purpose: To see if there is an association between physician assistants' academic degrees and practice in primary care, in rural areas, and with the medically underserved. Methods: Surveys were sent to 880 graduates of the first 32 University of Washington physician assistant classes through 2000. Respondents noted their academic degree at program entry and the highest degree attained at any time up to the time of survey. Relationships between practice characteristics and academic degree levels were tested by unadjusted odds ratios and logistic regression after controlling for year of graduation and sex. Results: Of the 478 respondents, 54% worked in primary care, about 30% practiced in nonmetropolitan communities, and 42% reported providing care for the medically underserved. Respondents with no degree (33% of total at entry, 24% at survey) were significantly more likely than degree holders to work in primary care and nonmetropolitan areas. Respondents with no degree at program entry were significantly more likely, and those with no degree at the time of the survey were marginally more likely, to self-report work with the medically underserved. Conclusion: Respondents with no academic degree are significantly more likely to demonstrate a commitment to primary, rural, and underserved health care. These findings may inform the national debate about the impact of required advanced degrees on the practice patterns of nonphysician providers.
Freeman VS, Tijerina, S. Delivery methods, learning styles, and outcomes of physician assistant students. Physician Assistant. July 2000;43-50.
Abstract: The delivery of allied health education has changed in the past 5 years to include distance education courses using technologic methods. Although the effectiveness of these methods has been studied, little research has been performed on student learning outcomes in distance education based on individual learning characteristics. The purpose of this quasi-experiment was to compare 2 types of delivery methods for physician assistant students - the technology-drive method at distance sites versus the on-site method - and physician assistant student learning styles in terms of learning outcomes. Results showed no relationship between a student's learning style and the method of delivery on learning outcomes. The impact of this study is on program directors and faculty, who may need to offer distance didactic courses using interactive video teleconferencing, and on students whose only method to obtain an education in allied health studies is through distance learning.
Fuchs E. PAs: Not a silent partner. AAMC Reporter. January 2009.
Glicken AD, Gray J. Adaptation of PA students to medical training. JAAPA. June 1993;6(6):442-448.
Abstract: Recent research in medical education has focused on the psychologic effects of training on medical students. This study of PA students used standardized measures and was designed to help clarify how personality and social and developmental factors contribute to feelings of stress, dysphoria, and depression. Unlike studies of medical students, this study revealed a low incidence of depression, with no significant sex differences at any assessment. At the final testing, masculinity, as a personality trait, was moderately associated with lower depression scores. Although a weak association also existed between a history of parental depression and depressive symptoms in students, no relationship was seen between family history of alcohol use and student depression. In addition, reported drug and alcohol use was low, and no relationship existed between these variables and depressive symptomatology. Future research on the influence of situational stress during medical training versus the influence of personality factors is needed.
Glicken AD. Excellence in physician assistant training through faculty development. Academic Medicine. Nov 2008; 83(11):1107-1110.
Abstract: Once again, experts predict a shortage of health care providers by 2020. The physician assistant (PA) profession was created in the 1960s to address a similar need. Currently, there are 141 accredited PA training programs in the United States, 75 of them established in the 10 years between 1993 and 2002. Historically, PA education and practice models have been responsive to the ever-changing landscape of health care. It may be the profession’s flexibility and adaptability that has enabled it to survive and flourish in a competitive service environment. The growth of new PA programs mandates a need for continuing faculty development, as increasing numbers of educators hail primarily from clinical practice and come equipped with minimal teaching experience. PA faculty development addresses these new recruits’ needs to develop model curricula, implement new courses, and enhance instruction — all with the goal of improving both access to and quality of health care.
The author describes the impact of Health Resources and Service Administration Title VII, Section 747 (Title VII) contracts in addressing this need. Title VII-funded PA education projects, considered innovative at the time of implementation, included both faculty development workshops that promoted active learning of basic teaching and administrative skills and new curricula designed to enhance faculty teaching in genomics and practice management. These projects and others resulted in enduring professional resources that have not only strengthened the PA community but also enjoyed broad applicability within other health professions groups.
Gray J, et al. Do PAs use the procedures and skills they learn? JAAPA. Feb 1995;8(2):45-51.
Abstract: The purpose of the study is to update and expand on data that identifies diagnostic and clinical procedures used by PAs. Data from a self-report questionnaire that was mailed to 332 PAs practicing in Colorado shows that most respondents learned the 39 listed clinical procedures in their PA education program. Although most PAs learned them adequately, they do not regularly perform most of the procedures. Eight procedures (reading chest and long-bone X-ray films, suturing, splinting, interpreting ECGs, and performing pelvic examinations, Papanicolaou tests, and dipstick urinalysis) were used more than once a month by at least 505 of respondents. However, approximately 55% of respondents believe that they adequately learned how to interpret ECGs and read chest and long-bone X-ray films during their PA education program. Three procedures (cardiopulmonary resuscitation, lumbar puncture, and suprabpuc aspiration) are used less than once a year by more than 90% of respondents. PA education programs may want to consider whether to continue teaching the technical skills that are necessary to perform these procedures.
Henderson, TM. Financing Medical Education by the States. Forum for State Health Policy Leadership, National Conference of State Legislatures. August 1998.
Jones, PE. Physician assistant education in the United States. Academic Medicine. Sept 2007; 82(9):882-887.
Abstract: As physician assistant (PA) programs developed in the 1960s, curriculum models emerged around the central themes of physician-dependent practice and competency-based education. By 2007, there were 136 accredited programs in the United States, with 108 (79%) offering a master-degree curriculum. PA program preclinical and clinical curricula are typically evenly divided in length, and the typical U.S. PA program has a full-time attendance curriculum of 26.5 continuous months. In academic year 2005-2006, the typical PA student was a 27-year-old white woman with a 3.4 overall grade point average and 29 months of prior health care experience who matriculated with a baccalaureate degree into a master-degree PA program. In the 2005 application cycle, the number of applicants per available seat was 2.25 for both allopathic medical schools and PA programs. The transition to a predominately master-degree curriculum resulted in new challenges for PA faculty development, and the number of PA educators with terminal academic degrees continues to lag behind the educational needs ot training programs. The topic of PA specialty training and recognition remains controversial. Although the PA profession has prospered since inception, concerns exist regarding workforce issues such as the appropriate balance of autonomy and supervision, role delineation, and the continuing trend toward specialization. The omission or inaccurate classification of PAs within U.S. health care access and workforce literature projects an incomplete picture, and it is important to consider the contributions PAs have made and will continue to make in addressing the nation’s health care needs.
Kasovac M. Osteopathic medical education in the 21 st century-Translating educational challenges into professional opportunities. JAOA. Aug 1999;99(8):405-407.
Lichter PR. Confusing licensure with education: medicine's slippery slope. Federation Bulletin. 1995; 82(1):16-20.
Mullan F. Some thoughts on the white-follows-green law. Health Affairs. 2002; 21(1):158-159.
Oliver DR. Highlights from the Ninth Annual Report on PA Educational Programs in the US 1992-1993. JAAPA. 1994;7(4):273.
Reines HD, et al. Integrating midlevel practitioners into a teaching service. Am. J. Surg. 2006;192:119-124.
Abstract: Meeting the educational needs and requirements of surgical resident physicians while achieving optimal patient care is a challenge for program directors. Midlevel practitioners (MLPs) were employed by a large community teaching hospital to augment the surgical teaching service, to improve continuity of patient care, and to provide resident physicians with greater flexibility to participate in classroom, operative, and clinical educational experiences. The MLPs were carefully integrated into the surgical program by creating the necessary buy-in, developing positive relationships, decreasing resistance, and reinforcing acceptance when demonstrated. MLPs function at the level of junior resident physicians and are active participants in the teaching and evaluation process. Structurally, MLPs receive their assignments from and report to the chief resident physician, but are ultimately responsible to the program director. Instituting the program required providing financial justification to administration and flexibility in meeting the diverse needs of the four teams. As a result, surgical resident physicians have been sufficiently freed from service activities to be able to capitalize on learning activities that range from surgeries to conferences. MLPs can be integrated into a surgical teaching program and become a positive force in the education of resident physicians.
Reynolds PP. Why we need to restore primary care generalist training as the centerpiece of federal policy [edit.]. Academic Medicine. Nov 2008; 83(11):993-995.
The role of Title VII, Section 747 in preparing primary care practitioners to care for the underserved and other high-risk groups and vulnerable populations. Sixth annual Report to the Sec of the US Dept of HHS and to Congress. Advisory Committee on training in primary care medicine and dentistry. November 2006.
Schmitz B, et al. Instructing PA students with interactive videoconferencing. Physician Assistant. June 1997;143-147.
Abstract: Interactive videoconferencing expands the classroom beyond traditional boundaries. A series of health care courses was taught by satellite to students enrolled in a PA training program. A study of the students' perception of this teaching method was positive. Various advantages and disadvantages, as well as suggestions for improvement, are discussed.
Spiro H. Why not nurse practitioners and physician assistants? YJHM. Nov 2, 2007.
Wilson WM, et al. Shaping a model clinical therapeutics curriculum. JAAPA. May 1995;8(5):51-54.
A workable model for teaching clinical therapeutics to PAs may be available by 1996. Here, representatives from PA programs involved in the curriculum project report on its driving forces, progress, and future.
Job Satisfaction
Liu, CM, et al. An analysis of job satisfaction among physician assistants in Taiwan . Health Policy. 2005;73:66-77.
Abstract: The physician assistant (PA) is a relatively new medical specialty that developed to manage the shortage of resident physicians and to ensure that patients receive high-quality health care in today's increasingly complex and demanding medical environment. PAs in Taiwan are not governed by laws and regulations, and the absence of legislation to define their roles and responsibilities can lead to confusion in the work environment and potential communication barriers with coworkers and supervising physicians. The purpose of this exploratory study was to examine the environmental and sociodemographic factors that influence job satisfaction and job-related communication among PAs in Taiwan. The data source, a self-administered mail survey, was sent to 196 PAs working within medical facilities in northern, central, and southern Taiwan. The response rate to the survey was 71.01%. There was a strong correlation between communication satisfaction and job satisfaction among respondents. The PAs' overall position in the hospital, relationships with coworkers (doctors, nurses, and other medical staff), and ability to perform his or her duties while working with the supervising physician were the major environmental factors that influenced job and communication satisfaction. In addition, the number of working years and marital status were important demographic factors influencing job satisfaction. Demographic and environmental factors influencing job satisfaction are analyzed, and ways in which the roles and responsibilities of PAs can be clarified, strengthened, and improved are discussed in an overall effort to provide management strategies for the current PA system in Taiwan.
Legal Issues
Albert T. Avoid legal pitfalls when hiring physician extenders. Am Med News. July 14 2003; www.ama-assn.org/sci-pubs/amnews/pick_03/prca0714.htm.
Brock R. The malpractice experience: How PAs fare. JAAPA. June 1998; 11(6):93-4.
Byous RS. A Policy Analysis Case Study of How Access to Health Care has Influenced Legislation that Impacts PA Practice in the States of CA, MD, and TX. March 2201. Dissertation. School of Organizational Management, Department of Public Administration, University of La Verne, La Verne, CA
Davis A, Gara N, Powe M. Regulation, reimbursement, and PA practice today. JAAPA. January 1999; 12(1):17-40.
Desmarais H. Government health policy and the nonphysician provider: a closer look. JAAPA. Mar 1994;7(3):195-9.
Estes EH, Carter RD. Accommodating a New Medical Profession: The History of Physician Assistant Regulatory Legislation in North Carolina. NC Med J . March/April 2005;66(2):103-107
Gara N, Davis A. The political process. In Ballweg R, Stolberg S, Sullivan E. Physician Assistants: A Guide to Clinical Practice. 2003; Chapter 4: 50-69. Saunders, Philadelphia , PA.
Goldberg DJ. Laser Physician Legal Responsibility for Physician Extender Treatments. Lasers in Surgery and Medicine. 2005;37:105-107.
Background and Objective: Increased demand for non-invasive cosmetic laser procedures has led to an increase in the use of physician extenders (PE). This demand has now led to a variety of medical legal concerns surrounding the use of lasers by non-physician PE. Study Design: This review looks at the evolution of the relationship between physicians and the various types of PE. The focus of the manuscript is on the variety of legal issues that may arise because of this relationship. Physicians are increasingly utilizing PE in their laser facilities leading to potential legal issues. Conclusions: An understanding of these legal issues will lead to better defensive practices by both the physician and PE.
Gore CL. A Physician's liability for mistakes of a physician assistant. The Journal of Legal Medicine. 21: 125-142.
Green J. The threat of the domino effect. American Medical News. June 21, 1999: 9,11.
This article describes the political climate as some nonphysician practitioners seek to expand scope of practice through legislation. The author presents responses of the AMA and the Federal of State Medical Boards.
Hooker RS, Nicholson JG, Le T. Does the employment of PAs and NPs increase liability? J Med Lic & Discipline. 95(2):6-16.
Abstract: We assessed whether physician assistant (PA) and nurse practitioner (NP) utilization increases liability. In totl, 17 years of data compiled in the United States national Practitioner Data Bank (NPDB) was used to compare and analyze malpractice incidence, payment amount and other measures of liability among doctors, PAs and advanced practice nurses (APNs).
From 1991 through 2007, 324,285 NPDB entries were logged, involving 273,693 providers of interest. Significant differences were found in liability reports among doctors, PAs and APNs. Physicians made, on average, malpractice payments twice that of PAs but less than that of APNs. During the study period the probability of making a malpractice payment was 12 times less for PAs and 24 times less for APNs. For all three providers, missed diagnosis was the leading reason for malpractice report, and female providers incurred higher payments than males. Trend analysis suggests that the rate of malpractice payments for physicians, PAs and APNs has been steady and consistent with the growth in the number of providers.
There were no observations or trends to suggest that PAs and APNs increase liability. If anything, they may decrease the rate of reporting malpractice and adverse events. From a policy standpoint, it appears that the incorporation of PAs and APNs into American society has been a safe and beneficial undertaking, at least when compared to doctors.
Lavia LA. EMTALA: A general guide for the physician assistant. JAAPA. Sept. 2002;15(9):15-19.
Lenzer JM. Whistle-blowing dilemma [letter, comment]. JAAPA. Jan 1994; 7(1):65.
Lieberman D, Lalwani A. Physician-only and physician assistant statutes: a case of perceived but unfounded conflict. Sept/Oct 1994; JAMWA. 49(5):146-49.
In the 1970s, after the US Supreme Court declared in Roe v Wade that a woman has a fundamental right to terminate a pregnancy, most states enacted laws decriminalizing abortion. Generally, these statutes legalized abortion when performed by a physician. (Only six states — AZ, KS, NH, OR, VT, WV — do not require explicitly that abortions be performed by physician.) At around the same time, but for different reasons, most states adopted regulatory measures establishing and defining the profession of physician assistant (PA). These laws broadly define the scope of practice of PAs as the practice of medicine by trained and licensed professionals under the supervision of physicians. Inconsistencies between physician-only abortion laws and PA statutes have generated confusion in the medical community as to whether PAs, working under the supervision of physicians, can legally perform abortions. Using three case studies, this article examines the statutory dynamic against the backdrop of the severe and intensifying shortage of trained abortion providers in the United States. The authors conclude that the perceived conflict between physician-only and PA statutes should not preclude PAs from providing this vital service.
McLean TR. Crossing the quality chasm: autonomous physician extenders will necessitate a shift to enterprise liability coverage for health care delivery. Health Matrix. Summer 2002; 12(2):239-295.
Moses RE, Feld AD. Physician liability for medical errors of nonphysician clinicians: Nurse practitioners and physician assistants. Am J Gastroenterol. 2007;102:6-9.
Safriet BJ. Impediments to progress in health care workforce policy: license and practice laws. Inquiry. Fall 1994; 31:310-317.
Any meaningful reform of health care delivery will have to overcome current barriers to effective utilization of nonphysician providers. These barriers include cultural and professional realities, as well as a number of explicit legal impediments. Medical practice acts remain overly broad and indeterminate, with concomitant and unnecessary restrictions in the licensure and practice acts of nonphysician providers. If we are to achieve our goal of offering high-quality care, at an affordable cost, to everyone who needs it, we must ensure that all health care providers are able to practice within the full scope of their professional competencies.
Slaughter J. Prescriptions and protocols. Kansas Physician. March 1999;4(10):2.
Strand J. Enabling legislation for physician assistants in Puerto Rico: a sociocultural policy analysis. UNC School of Public Health, Chapel Hill, 2008.
Abstract: Puerto Rico is the last large jurisdiction in the United States without enabling legislation for physician assistants (PAs). This qualitative inquiry seeks to characterize the barriers to, and potential facilitators of implementation of physician assistants in the Commonwealth of Puerto Rico, and recommend strategies for implementation. Twenty-five semi-structured interviews were conducted in Puerto Rico in January 2008, from a purposeful sample of practicing physicians, medical educators, members of the legislative and executive branches of government, health system executives, and physician assistants with knowledge of Puerto Rico. Interviews were conducted in English and Spanish and digitally recorded and transcribed by the investigator. Analysis of the transcribed interviews identified themes which were coded and grouped for convergence and divergence of perspectives. Antagonist themes asserted there is not shortage of physicians, that geographic and primary care access is good, that patients will not accept PAs, and PAs will experience a negative practice environment with respect to malpractice and reimbursement, as do physicians. Proponent themes argued there are transportation barriers to care, delays in access to specialist care, substandard primary care by generalist physicians, the majority of whom are international medical graduates, elite physician flight from the island, and PA-like roles that have been created “below the radar,” demonstrating the need for PAs. Cross-cutting themes include organized medicine and nursing opposition, overall loss of physicians from the island, increasing health care costs, lack of unanimity and policy action by organized medicine, and poor understanding of PAs. Strategic recommendations include a public relations campaign targeted at physicians and legislators, and a dedicated lobbyist located in Puerto Rico. An initial pilot implementation is recommended in the medical and surgical subspecialties at the University of Puerto Rico Medical Center, with future primary care demonstration projects on the islands of Vieques and Culebra and in the rural community of Castaner. Pilot projects should include prospective evaluations, including cost, quality and patient satisfaction outcomes.
Suit Arising from Physician Assistant's Services Raises Supervision Questions. Hospital Law Newsletter. April 2002; 19(6): 1-3.
Weber RD. New rules authorizing physicians to delegate the prescribing of controlled substances present significant legal liability exposure. Michigan Medicine. December 1999;98(12).
Michigan's new rules authorizing physicians to delegate the prescribing of controlled substances to physician assistants (PAs) or nurse practitioners and nurse midwives (APNs), because effective November 17, 1999. The rules were vigorously opposed by the Michigan State Medical Society on the basis that prescribing controlled substances by non-physicians presented a serious health risk to the public.
Licensure and Certification
Crane SC , Carpenter D. Perspectives on the physician assistant specialty credentialing debate. JAAPA. Aug 2006; 19(8):16-20.
Lichter PR. Confusing licensure with education: medicine's slippery slope. Federation Bulletin. 1995; 82(1):16-20.
McGowan E. The "doctor" debate continues. [letter, comment]. JAAPA. Sept 1996;9(9):114.
Perry J, et al. A Study of Physician Assistant Licensure. December 2005; Legislative Research Commission, Frankfort, Kentucky.
Marketplace Determinants
Aiken LH. Achieving an interdisciplinary workforce in health care. N Engl J Med. Jan 9 2003;348(2):164-166.
Are PAs America's next health care heroes? Still. Spring 2009; 4(2):14-17.
Armitage M, Shepherd S. A new professional in the healthcare workforce: role, training, assessment and regulation. Clinical Medicine. August 2005;5(4):311-314.
Barer M. New opportunities for old mistakes. Health Affairs. 2002; 21(1):169-171.
Blynn L. Taking Stock: Recruiters and PAs disagree on the job market. Advance for PAs. March 2003:54-56.
According to certain recruiters, PA jobs are available, but competition is fierce because of market saturation. Many of the available jobs are not in desirable locations and specialties.
Cawley JF, Simon AF, Blessing JD, Pedersen D, Link M. Marketplace demand for physician assistants; results of a national survey of 1998 graduates. Perspective on Physician Assistant Education. Winter 2000; 11(1):12-17.
Introduction: The marked increase in the numbers of annual PA graduates over the past five years, coupled with the continuing output of new physicians and the significant expansion of other nonphysician professions, have raised questions regarding the current and future marketplace demand for PA graduates. There is a need to gather data on the initial employment experiences of PA graduates. Methods: We conducted a national cross-sectional survey of 1998 PA graduates using a mailed questionnaire to assess their experiences in searching for initial PA employment and perceptions of market demand. A random sample of 1,500 subjects were administered a questionnaire comprising three categories: demographics, initial employment experiences, and perceptions of marketplace demand. In the perception portion of the study, 10 statements were posed to participants to assess their views of their search for initial employment and perceptions of the marketplace demand for PAs in their region. Results: Of respondents (N=723), 66% were women; the mean age was 32 years; the range of ages was 21-59 years; 14% were racial/ethnic minorities. Nearly all in the sample were eligible for employment as PAs. Of 723 who responded to the survey, 715 actually sat for the PANCE exam, and 697 (96.4%) passed. A strong majority, 664 (92%) of respondents, had found employment as a PA by the time they completed the survey; of the 664 positions held, 600 (90.3%) were full-time positions. Respondents attended a mean of 3.18 job interviews, and received an average of 2.07 job offers. a majority of respondents, 539 (81.1%) of those who had secured jobs either full-time or part-time, secured employment within the first 8 weeks after graduation. Only 8%, or 57 respondents, indicated that they were not employed as PAs, 47 of whom had passed the PANCE. Responses varied considerably according to region (APAP Consortium regions) and by state. While respondents tended to be somewhat dissatisfied with the number of job offers presented to them (mean rating 2.5), they appeared to be more satisfied with the salary level (mean 3.4) and benefits (mean 3.5) of the position they accepted. Conclusions: The vast majority of 1998 PA graduates, versus 92.2% (657 or 712) reported in a survey of 1997 PA graduates. There appeared to be a perception, in particular among respondents on the east and west coasts, that the PA job market was not strong. Respondent perceptions revealed dissatisfaction with the number of job offers presented to them (mean rating of 2.5), disagreement with the notion that there were plenty of jobs (mean rating of 2.40), and disagreement with the idea that the job market is strong (2.06). Further study of the initial experiences and marketplace perceptions of recent PA graduates should continue in a time of a fast and vastly changing medical care environment.
Coffman J, et al. Is there a doctor in the house? An examination of the physician workforce in California. June 2004; Petris Center on Health Care Markets and Consumer Welfare. UC Berkeley:108pp.
Executive Summary: Physicians are a key component of California's health care system. Their contributions to the idagnosis and treatment of illness are critical to the well-being of the state's population. California's citizens and its policymakers need to know how the state's physicians have responded to the dramatic changes in health care in the United States over the past 25 years. This report, prepared by the Petris Center on Health Care Markets and Consumer Welfare, presents important new findings about long-range trends in physician supply in California, as well as a snapshot of the state's current physician workforce. Most of our data are from the American Medical Association's Masterfile, the most comprehensive and systematic source of data regarding physician practice in the United States. The report addresses vital issues such as whether the state has a sufficient number of physicians, whether physicians are adequately distributed with respect to specialty and geographic location, the extent to which they are meeting the needs of the state's racially/ethnically diverse population, and the growing importance of nurse practitioners and physician assistants.
Colwill JM, Cultice JM, Kruse RL: Will generalist physician supply meet demands of an increasing and aging population? Health Affairs. 2008;27(3):232-241.
Abstract: We predict that population growth and aging will increase family physicians’ and general internists’ workloads by 29 percent between 2005 and 2025. We expect a 13 percent increased workload for care of children by pediatricians and family physicians. However, the supply of generalists for adult care, adjusted for age and sex, will in crease 7 percent, or only 2 percent if the number of graduates continues to decline through 2008. We expect deficits of 35,000-44,000 adult care generalists, although the supply for care of children should be adequate. These forces threaten the nation’s foundation of primary care for adults.
Cooper RA, Getzen TE, McKee HJ, Laud P. Economic and demographic trends signal an impending physician shortage. Health Affairs. 2002; 21(1):140-154.
Abstract: It is widely believed that the United States is producing too many physicians. We have approached this issue by developing a new model for workforce planning based on assessments of the macrotrends that underlie the supply and use of physician services. These trends include economic expansion, population growth, physicians' work effort, and the provision of services by nonphysician clinicians. Contrary to earlier predictions, this model projects that the United States soon will have a shortage of physicians and that if the pace of medical education remains unchanged, the shortage will become more severe. A dialogue focused on that eventuality is imperative.
Cooper RA. Health care workforce for the twenty-first century: the impact of nonphysician clinicians. Annual Review of Medicine. 2001; 52:51-61.
Abstract: For many years, nonphysician clinicians (NPCs) have participated in the care of patients. However, their numbers were small and their licensed prerogatives were narrow. Over the past decade, these characteristics have changed in three important ways. First, training in many of the NPC disciplines had increased substantially, and the growth of these disciplines is accelerating. Second, state laws and regulations have expanded both the practice prerogatives of NPs and their autonomy from physician supervision. Third, payers have increased their access to reimbursement. As a consequence, NPCs are undertaking many elements of care that previously were provided by physicians. Their participation is generally cost-effective and is met with a high degree of patient satisfaction. This presents both opportunities and challenges to physicians as they forge new relationships with NPCs and as their own spectrum of responsibility evolves.
Cooper RA. New directions for nurse practitioners and physician assistants in the era of physician shortages. Academic Medicine. Sept 2007; 82(9):827-828.
Abstract: During the past 35 years, the roles for nurse practitioners (NPs) and physician assistants (PAs) have evolved in parallel with the roles that physicians have come to play. Shifting needs in primary care and expanding opportunities in specialty medicine have been the dominant trends. Future directions will be influenced additionally by the deepening physician shortage. NPs are preparing for this future by developing doctoral-level training programs in comprehensive care, whereas PAs are adding training opportunities in specific specialties. Yet, neither discipline has expanded its training capacity to the degree that will be required, and, like physicians, neither will have a supply of practitioners that will match future demand. Coordinated planning to increase the educations infrastructure for physicians, NPs, and PAs is essential.
Cooper RA. Scarce physicians encounter scarce foundations: A call for action. Health Affairs. 23(6):243-249.
Abstract: The United States is in the early phases of a deepening shortage of physicians, a situation last experienced fifty years ago. As then, energy and creativity will be needed to meet the nation's needs, and U.S. philanthropic foundations will again be called upon to play leadership roles. The issues are broad - extending from medical education to regulation and from building new schools to recruiting more international medical graduates. Throughout these issues, foundations are uniquely positioned to convene stake-holders, fund analyses, foster new medical education paradigms, and support the growth of its infrastructure. Foundations will be necessary partners in what is to come.
Dehn RW. The shrinking PA applicant pool threatens our future. JAAPA. Sep 2002; 15(9):6,8,10.
Dill MJ, Salsberg ES. The complexities of physician supply and demand: projections through 2024. Association of American Medical Colleges, Center for Workforce Studies. Nov 2008.
Druss BG et al. Trends in care by nonphysician clinicians in the U.S. N Engl J Med. Jan 9 2003;348(2):130-137.
Abstract
Background: The 1990s saw rising numbers of graduates of training programs for nonphysician clinicians, passage of legislation expanding their scope of practice, and a pr4oliferation of managed-care models that emphasized the use of these providers as a strategy for containing health care costs. Methods: We used two nationally representative surveys to examine trends in outpatient care provided by physicians and nonphysician clinicians between 1987 and 1997, adjusting for the case mix. Analyses examined care provided by 10 categories of nonphysician clinicians: chiropractors, midwives, nurses or nurse practitioners, optometrists, podiatrists, physician assistants, physical or occupational therapists, psychologists, social workers, and others. Results: Between 1987 and 1997, the proportion of patients who saw a nonphysician clinician rose from 30.6 percent to 36.1 percent (adjusted relative risk for 1997 as compared with 1987, 1.42 [95 percent confidence interval, 1.35 to 1.50]). The trend was driven by an increase in the proportion of persons who visited both a physician and a nonphysician clinician (from 23.5 percent to 30.9 percent; adjusted relative risk, 1.49 [ 95 percent confidence interval, 1.40 to 1.58]), rather than an increase in the proportion who saw only a nonphysician clinician (from 7.2 percent to 5.3 percent; adjusted relative risk, 0.81 [95 percent confidence interval, 0.70 to 0.93]). This pattern was consistent in analyses of specific medical conditions and specific types of nonphysician clinicians. There was an increase in the proportion of patients obtaining preventive services from nonphysician clinicians and a decline in the proportion receiving acute care services from such clinicians. Conclusions: From 1987 to 1997, there was a degree of differentiation between physicians and nonphysician clinicians with respect to the services they provided but not with respect to the patients they treated. The implications of these findings hinge on the degree to which the increase in conjoint service delivery represents growing coordination or fragmentation of care.
Forrer M. Evaluation of the role of Physician's Assistant. July 2003; Northeast London Workforce Development Confederation. 51pp.
Fowkes V, Gamel N. The California physician assistant workforce: a 10-year perspective. Perspective on PA Education. 2000;11(3):152-156.
Educators and policy-makers concerned about primary-care workforce issues in California have conducted surveys with physician assistants (PAs) to learn more about their locations, practice features, and the extent to which they provide care for underserved populations. Method: In 1998, a statewide survey was administered to all PA licensees (2,938) in California . This survey was similar to one administered in 1988 to 1.263 PAs. Results of the two surveys were compared. These results also were compared with results from the 1998 national census conducted by the American Academy of Physician Assistants (AAPA). The 1998 California survey also included all nurse practitioner (NP) licensees, allowing comparison between state PAs and NPs. Results: A 58% response from PAs in the 1998 study revealed that the California PA workforce increased by 65% between 1988 and 1998. Minority PAs increased by 7%. California had 20% more minority PAs compared to the PA workforce nationally. Sixty-one percent of California PAs were practicing in the primary-care specialties, compared with 54% in the national census. In 1998, 54% of California PAs reported substantial involvement (more than 15% of their patients) with Medicaid recipients, 34% with the uninsured, 71% with minorities, and 50% with patients who spoke limited English. These percentages increased substantially over the 10-year comparison period. When compared with NPs in the California study, PA licensees were fewer in number (7,341 vs. 2,938), and PAs were of greater ethnic diversity (29% minority compared to 18% among NPs). NPs were more likely than PAs to practice in the primary-care specialties (75% vs. 61%). A significant percentage of both groups (39%) practiced in underserved settings and reported similar levels of involvement with underserved groups of patients. More fo the PAs than NPs (16% vs. 12%) were in state-designated rural areas, and more PAs than NPs (21% vs. 17%) were in federally designated Health Professional Shortage Areas (HPSAs). Conclusion: California PAs, along with their NP colleagues, are growing in numbers and increasingly practicing primary care in areas of need and with underserved populations.
Fraher E, Shadle J, Smith L. Trends in the Supply of Nurse Practitioners and Physician Assistants in North Carolina, 1990-2001. Chapel Hill: North Carolina Rural Health Research and Policy Analysis Center, UNC. June, 2003.
Green J. Physician extenders in greater demand. American Medical News. July 24, 2000: 11-12.
Grumbach K, Coffman J. Physicians and Nonphysician Clinicians: Complements or competitors? JAMA. Sept 2, 1998;280(9):825-826.
Grumbach K. The ramifications of specialty-dominated medicine. Health Affairs. 2002; 21(1):155-157.
Health and Health Care 2010: The Forecast, the Challenge. Robert Woods Johnson Foundation. Princeton, NJ. www.rwjf.org/iftf/intro.htm.
Hecker DE. Occupational employment projections to 2010. Monthly Labor Review. 2001;124(11):57-84.
Abstract: Total employment is projected to increase by 22.2 million jobs over the 2000-10 period, rising to 167.8 million, according to the latest projections of the Bureau of Labor Statistics. This increase represents about a million more jobs than were added over the previous 10-year period (1990-2000). The projected 15.2-percent increase, however, is less than the 17.1-percent increase of the previous 10-year period. Self-employed is projected to grow from 11.5 to 11.7 million, or 1.7 percent.
The economy will continue generating jobs for workers at all levels of education and training, although growth rates are projected to be faster, on average, for occupations generally requiring a postsecondary award (a vocational certificate or other award or an associate or higher degree), than for occupations requiring less education or training. Most new jobs, however, will arise in occupations that require only work-related training (on-the-job training or work experience in a related occupation), even though these occupations are projected to grow more slowly, on average. This reflects the fact that these occupations accounted for about 7 out of 10 jobs in 2000.
Hooker RS. Federally employed physician assistants. Military Medicine. Sept 2008;173(9):895-899.
Abstract: The federal government is the largest single employer of clinically active physician assistants (PAs) in the United States, with > 3,000 PAs in 2008. PAs are present within the Departments of Defense, Veterans Affairs, Health and Human Services, Justice, and Homeland Security. Most are civil servants or hold a commission in the uniformed services. Most employing agencies have expanding needs for PAs. This overview presents a framework of how PAs are being used and the critical roles they plan in the federal health care system. Because civilian job opportunities for PAs are plentiful, the federal system is seeking strategies for recruitment and retention. A centralized plan may be one useful recommendation.
Hooker R, Berlin LE. Trends in the Supply of Physician Assistants and Nurse Practitioners in the United States. Health Affairs. Sept/Oct 2002;21(5):174-181.
Abstract: In 2001 an estimated 103,612 nurse practitioners (NPs) and physician assistants (PAs) were in clinical employment in the United States . The roles of PAs and NPs in providing comparable physician services are similar; they differ in that NPs are predominantly in primary care, while PAs are divided between primary and specialty care. PA and NP education processes also differ in the student pool and trends in the output. The combined number of graduates totaled 11,585 in 2001. However, the annual number of NP graduates is declining, while the number of PA graduates is increasing. These observations have implications for the future in the types of patients they see and the degree of health care services they provide.
Jolly, R. Health workforce: a case for physician assistants? Parliament of Australia. Department of Parliamentary Services, Social Policy Section. March 25, 2008.
This paper outlines the development of the physician assistant model in the United States, Britain and Canada and considers the possible application of the model to the Australian health system. The paper concludes there is potential to adapt this model to suit the Australian health system so that quality of care and safety in the delivery of services is not compromised.
Jones PE, Hooker RS. Physician assistants in Texas. J Texas Medicine. 2001; 97(1): 68-73.
Understanding the health requirements of a state begins with identifying the population at need and the workforce available to meet those needs. A descriptive study was undertaken to examine the physician assistant (PA) workforce in Texas as part of an ongoing effort to meet the health needs of Texas residents. In September 2000, Texas had 2237 licensed PAs practicing in 186 countries. Education for PAs in Texas began in 1970 and currently includes one private, one military, and six public programs. Most practicing PAs in Texas graduate from in-state programs and tend to locate within the state. Preparations are under way to shift the public undergraduate programs to graduate degree programs. Although barriers to health care access in Texas remain a substantial public health issue, PAs have helped reduce these barriers, especially in many rural communities. The supply of and demand for Texas PAs appear to be in equilibrium. Policy implications are discussed.
Knapp KK, et al. Availability of primary care providers and pharmacists in the United States. J Am Pharm Assoc (Wash). 1999 Mar-Apr;39(2):127-135.
ABSTRACT: Objective: To determine the rural distribution of primary care providers (primary care physicians, physician assistants, nurse practitioners, and nurse midwives) and pharmacists. Design: Five-digit ZIP code mapping to study the availability of primary care providers and pharmacists, alone and in combinations, in rural areas and ZIP code-based health professional shortage areas (HPSAs). National averages for annual physician visits for hypertension, asthma, anad diabetes were used to estimate the sufficiency of the rural physician supply. Setting: Rural areas of the United States. Results: In rural areas, all providers were present in lower densities than national averages, particularly in HPSAs. The primary care physician supply was insufficient to meet national averages for ofice visits for hypertension, asthma, and diabetes. Among available providers, the most prevalent co-presence was primary care physician with pharmacist. HPSAs showed very low physician density (1 per 22,122), and the most prevalent providers were pharmacists. States varied widely in provider density. Conclusion: Despite longstanding efforts and the expansion of managed care, primary care providers remain in short supply in rural areas, especially ZIP code-based HPSAs. Making the best use of available providers should be encouraged. The continued shortfall of priamry care providers in rural areas, particularly HPSAs, makes it logical to use other available providers and combinations to increase health care access. Pharmacists could increase care for patients with conditions treated with medications. Other available providers, based on skills and work site, could also offset shortages.
Larson EH, et al. The contribution of NPs and PAs to generalist care in Washington state. HSR. Aug 2003; 38(4):1033-1050.
Objective: To quantify the total contribution to generalist care made by NPs and PAs in Washington State. Data Sources: State professional licensure renewal survey data from 1998-1999. Study Design: Cross-sectional. Data on medical specialty, place of practice, and outpatient visits performed were used to estimate productivity of generalist physicians, NPs, and PAs. Provider head counts were adjusted for missing specialty and productivity data and converted into family physician full-time equivalents (FTEs) to facilitate estimation of total contribution to generalist care made by each provider type. Principal Findings: NPs and PAs make up 23.4% of the generalist provider population and provide 21.0% of the generalist outpatient visits in Washington State. The NP/PA contribution to generalist care if higher in rural areas (24.7% of total visits compared to 20.1% in urban areas). The PAs and NPs provide 50.3% of generalist visits provided by women in rural areas, 36.5% in urban areas. When productivity data were converted into family physician FTEs, the productivity adjustments were large. A total of 4,189 generalist physicians produced only 2,760 family physician FTEs (1 FTE = 105 outpatient visits per week). The NP and PA productivity adjustments were also quite large. Conclusions: Accurate estimates of available generalist care must take into account the contributions of NPs and PAs. Additionally, simple head counts of licensed providers are likely to result in substantial overestimates of available care. Actual productivity data or empirically derived adjustment factors must be used for accurate estimation of provider shortages.
Larson EH, Hart LG. Growth and change in the physician assistant workforce in the United States, 1967-2000. J Allied Health. Fall 2007; 36(3):121-130.
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 emergency 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. The profession has grown rapidly; 56% of all PAs were trained between 1991 and 2000. In 2000, more than 42% of accredited PA programs offered a master’s degree, compared to master’s degree programs in 1986. Although many critical issues of scope of practice and patient and physician acceptance of PAs have been resolved, the PA profession remains young and continues to evolve. Whether the historical contribution of PAs to primary care for rural and underserved populations can be sustained in the face of increasing specialization and higher-level academic credentialing is not clear.
Lee BW. The PA profession: Does expansion have a downside? [letter, comment] JAAPA. June/July 1995;8(6):6.
Lindsay S. The Feminization of the Physician Assistant Profession. Women & Health. 2005; 41(4):37-61.
Abstract: Although the physician assistant profession has historically been male-dominated. women now comprise over sixty percent of physician assistants (PAs) in the U.S. This paper explores the reason for the increase of women into the physician assistant profession in recent decades and whether gender differences exist in how PAs are utilized. Twenty-one qualitative interviews with male and female physician assistants and key informants were conducted to assess the reasons for the influx of women. In addition, data from the American Academy of Physician Assistants Census Survey (n = 16,569) were analyzed to assess current gender differences in employment characteristics of PAs. In the interviews, female PAs reported entering the profession because it allowed them to practice within the medical model without having the high expense and demanding schedule of medical school. In fact, they claimed that the profession was quite compatible with family life. Significant gender differences were found in work characteristics, primary employer type, and practice specialty. Although women tend to concentrate in practice areas of women and children's health, evidence suggests that they are moving beyond these traditional roles into areas such as internal medicine and surgery.
Livengood R, Fraher E, Dyson S. Allied Health Vacancy Report. UNC at Chapel Hill, Sheps Center for Health Services Research, May 2005.
Lowes R. Where the jobs are. Medical Economics. Jan. 8, 2001.
McCann JL, et al. Physician assistant and nurse practitioner workforce trends. Oct. 2005; Robert Graham Center, Washington, DC. www.graham-center.org/onepager37.xml.
The physician assistant (PA) and nurse practitioner (NP) workforces have realized explosive growth, but this rate of growth may be declining. Most PAs work outside primary care; however, the contributions of PAs and NPs to primary care and interdisciplinary teams should not be neglected.
Michigan Department of Community Health. Survey of Physician Assistants 2007. Prepared by Public Sector Consultants. www.michigan.gov/documents/healthcareworkforcecenter/2007PHYSASSISTreport_230007_7.pdf
Morgan P, et al. Missing in action: care of PAs and NPs in national health surveys. Health Services Research. 2007
Objective: To assess applicability of national health survey data for generalizable research on outpatient care by physician assistants (PAs) and nurse practitioners (NPs). Data Sources: Methodology descriptions and 2003 data files from the National Ambulatory Medical Care Survey, the National Hospital Ambulatory Medical Care Survey, the Medical Expenditure Panel Survey, and the Community Tracking Study. Study Design: Surveys were assessed for utility for research on PA and NP patient care, with respect to survey coverage, structure, content, generalizability to the U.S. population, and validity. National estimates of patient encounters, statistically adjusted for survey design and nonresponse, were compared across surveys. Data Collection/Extraction Methods: Surveys were identified through literature review, selected according to inclusion criteria, and analyzed based on methodology descriptions. Quantitative analyses used publicly available data downloaded from survey websites. Principal Findings: Surveys varied with respect to applicability to PA and NP care. Features limiting applicability included (1) sampling schemes that inconsistently capture nonphysician practice, (2) inaccurate identification of provider type, and (3) data structure that does not support analysis of team practice. Conclusions: Researchers using national health care surveys to analyze PA and NP patient interactions should account for design features that may differentially affect nonphysician data. Workforce research that includes NPs and PAs is needed for national planning efforts, and this research will require improved survey methodologies.
Morgan P, Strand J. What about physician assistants? Letter. Health Affairs. May/June 2005; 24(3):886
Mullan F. Some thoughts on the white-follows-green law. Health Affairs. 2002; 21(1):158-159.
Mundinger MO. Through a different looking glass. Health Affairs. 2002; 21(1):163-164.
Norbut M. Physicians finding plenty of NPs, PAs - but at a price. Am Med News. May 5, 2003; www.ama-assn.org/sci-pubs/amnews/pick_03/bil20505.htm.
O’Connor TM, Hooker RS. Extending rural and remote medicine with a new type of health worker: Physician assistants. Aust. J. Rural Health. 2007;15:346-351.
Abstract: The purpose of this paper was to demonstrate that the medical workforce shortage is an international phenomenon and to review one of the strategies developed in the USA in the late 1960s: the physician assistant model of health service provision. The authors consider whether this model could provide one strategy to help address the medical workforce shortage in Australia. A systematic review of the literature about medical workforce shortages, strategies used to address the medical workforce shortage, and the physician assistant role was undertaken. Literature used for the review covered the period 1967-2006. Physician assistants provide safe, high-quality and cost-effective primary care services under the direction of a doctor and respond to workforce shortages in rural and remote areas, family practice medicine and hospital settings. This model of health care provision has been adopted in several other developed countries, including England, Scotland, the Netherlands and Canada. The physician assistant concept might provide Australia with a novel strategy for addressing its medical workforce shortage, particularly in rural and remote settings.
Percentage of Outpatient Department Visits in Which Only a Mid-Level Provider Was Seen, 1993-2004. MMWR. April 21, 2006;55(15):435.
Powe M, Hughes N. The role of physician assistants in the delivery of medical care. J Med Practice Mgmt. Sept/Oct 1999;73-76.
Reinhardt UE. Analyzing cause and effect in the U.S. physician workforce. Health Affairs. 2002; 21(1):165-166.
Simmons HJ, Rapoport DH. How will physician extenders affect our need for physicians? Healthcare Strategic Mgmt. Nov 2007;4-5.
Snyderman R, Sheldon GF, Bischoff TA. Gauging supply and demand: the challenging quest to predict the future physician workforce. Health Affairs. 2002; 21(1):167-168.
Stewart A, Catanzaro R. Can physician assistants be effective in the UK ? Clinical Medicine. August 2005;5(4):344-348.
Abstract: The National Health Service (NHS) faces a serious shortage of medical staff. one solution is to introduce US-style physician assistants (PAs) who train for around two years following previous clinical work or a first degree, and perform duties similar to junior doctors. This paper reviews the history and role of PAs, the quality of their work and their likely impact in the UK . A variety of sources were searched to identify suitable studies. The use of PAs in the UK appears to be an acceptable model that could eventually reduce the current skill shortage and provide high quality patient care. Twelve US-sourced PAs currently work in Sandwell, West Midlands. A recent report suggests they have made a substantial contribution to primary care and have improved patient access. For PAs to be successful in the UK , they must be highly regarded practitioners. High quality educational courses must be established to ensure their credibility.
Strand J, Dehn R. AAPA/APAP Research grant subcommittee interim report: What contributes to PA retention in rural communities? Nov 2004; 6 pp.
Weiner JP. A shortage of physicians or a surplus of assumptions? Health Affairs. 2002; 21(1):160-162.
Wilson JF. Primary care delivery changes as nonphysician clinicians gain independence. Annals of Internal Medicine. Oct. 2008; 149(8):597-600.
Minority PAs
Bowlin SD, Gugelchuk GM. The Use of Retention Strategies in Physician Assistant Programs to Retain and Graduate Minority Students. Perspective on Physician Assistant Education. Winter 2000; 11(1):7-11.
Physician assistant program directors across the country were interviewed about their use of retention strategies to retain and graduate minority PA students. Purpose: To determine the extent to which minority retention strategies are utilized in physician assistant programs and to describe the types of strategies used to retain and graduate minority students. The final purpose was to determine if there was a link between the use of particular strategies and the rate of minority student retention. Method: A descriptive study was conducted in 1997 via telephone interviews with the directors or director's designees from the 83 accredited physician assistant programs in the U.S. Results: 79 of 83 PA programs utilized retention strategies of some type. Of the 42 programs that also enrolled minority students, all employed a combination of tutoring, mentoring, and academic counseling, plus at least one additional strategy: prematriculation programs, special recruitment and retention focus programs, or early detection strategies. Minority retention success rates are dependent on the strategies employed, and program commitment to minority retention in general appears to influence the success that a program will have with any particular strategy. Conclusions: Student retention strategies are widely used by PA programs, and the strategies used appear to be successful in retaining minority PA students. However, success in the employment of these strategies appears to involve program commitment to retaining students in the context of an active learning partnership.
Hoyle MF. Notes/reflections based on personal experience [letter, comment]. Alaska Medicine. Apr/May/Jun 1997;39(2):50-52.
Abstract
Background: From 1980 through 1990, 16 Native Alaskan Community Health Aides and 21 non-Native Alaskans began physician assistant training at MDEDX Northwest at the University of Washington. This study was done to assess the outcome of training Native Alaskan health workers as physician assistants specifically whether Native Alaskan graduates are working in settings that serve Alaska Natives. Methods: The backgrounds, educational experiences and deployment locations of Native and non-native Alaskans accepted for training were compared using MEDEX Northwest student records. The 1991 graduate survey was used to compare differences in practice settings, specialty and salary between Native and non-Native graduates working in Alaska in 1991. Results: All of the non-Natives and 81% of the Natives completed the program, 100% of the Natives returned to Alaska where 91% found work as primary care physician assistants in clinics serving predominantly Native communities. By comparison 78% of the non-Native graduates returned to Alaska to work as physician assistants, 60% of them in primary care and 15% of them in predominantly Native communities. There were no significant differences in salary or benefits between Native and non-Native graduates. Conclusions: Physician assistant training for entry level health workers is a viable strategy for increasing the number of under-represented minorities in the health professions. The Native graduates of MEDEX Northwest are returning to communities where they serve Native people both as health care providers and as professional role models.
Valentine P. Cultural sensitivity in clinical practice. JAAPA. Nov 1994;7(10):687-688.
Overview
Adams D. More family doctors find PAs to be practice assets. Am Med News. Nov. 17, 2003; www.ama-assn.org/amednews/2003/11/17/prsd1117.htm.
Advanced nurse practitioners and physician assistants: what is the difference? Comparing the USA and UK. Hospital Medicine. 63(3).
With the reduction in junior doctors' hours and fewer doctors being trained in the UK , there is a need for other types of health-care practitioners to fill the gap. This article describes some of the background to the present situation and delineates two types of roles, the advanced nurse practitioner and the physician assistant, for consideration as alternatives to address the present and growing shortage of doctors.
Bayham D. The case for physician extenders. Arizona Medicine. Nov/Dec 2004:20,22.
Bluml BM, Copeland LR, LeTourneau B, Mundinger MO, Nelson R, Reinhardt U. Health Care Trends, Part 2. The New Health Care Team. Panel discussion. Physician Exec. 1999; July-Aug;25(4):67-75.
Brace FC. [Letter, commentary]. Del Med Jrl. Mar 1997; 69(30):161-2.
Browning J. Scope of Practice. Kansas Physician. March 1999; 4(9):2.
Buffa J. Physician extenders fill strategic staffing role. Medical Network Strategy Report. Date unknown.
Carter C. How valuable are physician assistants? Alliance. Mar/Apr 2002;28-33.
Carter RD , Strand J. Physician Assistants: a young profession celebrates the 35th anniversary of its birth in North Carolina. NCJM. Sept/Oct 2000;61(5):249-256.
The physician assistant (PA) profession began at duke University Medical Center. It celebrates its 35th birthday on October 6, 2000. The national success of PA programs can be traced to North Carolina's leadership in developing and using this new kind of health care professional. The North Carolina Medical Society, North Carolina Medical Board, state legislators, and state agencies like the Office of Rural Health and Area Health Education Centers (AHECs) worked together to make the program a reality. The evolution of the profession has been described in several articles in the North Carolina Medical Journal. We review here the development of the PA concept, the establishment of the profession, the expansion of the Duke curriculum from certificate to master's degree, and trends in practice characteristics of Duke PA alumni.
Chung K, Bell R, Coleman C. Evaluating the Utilization of Nonphysician Providers. Group Practice Journal. April 2002: 27-31.
Clerfond A. Report on status of PA profession in Queensland, Australia. April 2008; James Cook University School of Medicine & Dentistry. Townsville, Australia.
Cooper RA. The expanding scope of practice of nonphysician clinicians and implications for medical practice. J Medical Licensure and Discipline. 2003; 89(2):75-83.
Croasdale M. Empowered by insurers and states, nonphysicians push practice limits. Am Med News. Feb. 9, 2004; www.ama-assn.org/amednews/2004/02/09/prl10209.htm.
Curren J. Nurse practitioners and physician assistants: Do you know the difference? Medsurg Nursing. Dec 2007; 16(6):404-407.
Do physician assistants play a role in your practice? Urology Times. April, 2001.
Fleischer RD. A look at PA practice and prescription drug promotion. JAAPA. Nov-Dec 1995;8(10):41-56.
Frieden J. Patient demand spurs collaboration. Skin & Allergy News. Sept 1999; 30(9):1,4.
Glasz BP, Morrison GW. Advance directives: What your colleagues are thinking -- and doing. JAAPA. Oct 1995;8(9):51-63.
Abstract: We report on a survey of physician assistants' attitudes toward -- and experiences with -- advance directives. More than 46% of responding PAs have discussed advanced directives with their patients, and 40.9% have had experience with patients who have advance directives. More than 90% of PAs favor the use of advance directives, but men were more likely than women to believe that prolonging life is more important than honoring a patient's request to forgo life-sustaining treatment. PAs living in urban areas were more likely to be concerned that advance directives would lead to active euthanasia, and longer-practicing PAs showed more concern about the use of advance directives. Most PAs believed that, with few exceptions, most individuals should have the opportunity to complete an advance directive or treatment waiver.
Goldstein N. Look What's Next in Telemedicine: The Physician Assistant and Telemedicine. Hawaii Medical Journal. May 2005; 64(5):116.
Green J. Drug reps targeting nonphysicians. American Medical News. March 27, 2000.
Green J. Multiplying efforts. American Medical News. July 30, 2001 : 10-11.
Hamilton D. Healing powers. LA Times, Health section. Dec. 25, 2000;S-1.
Hooker R. Nonphysician Clinicians: The U.S. Experience. International Medical Workforce Conference, Oxford , England. September 2003.
Abstract: A significant shift in healthcare delivery has taken place in the U.S. over the last 35 years. The production of physician assistants (PAs) and nurse practitioners (NPs) has resulted in the presence of 110,000 clinically active nonphysician clinicians (NPCs). As of 2003, they comprise approximately one-sixth of the physician workforce and are well distributed throughout both primary care and specialty care. NPCs are more likely than physicians to practice in rural areas and where vulnerable populations exist. Productivity, based on traditional physician services, is comparable, and the range of services approaches 90 percent of what primary care physicians provide. The annual number of P/NP graduates is approximately 12,000, which rivals the 17,000 medical graduates produced each year. A number of national policies allows the education and training of NPCs to continue in order to backfill the growing demand for physician services.
Hooker RS, Mayo HG. Review of doctoral dissertations on physician assistants: 1972-2001. Physician Assistant. Feb 2003:28-34.
Abstract: To more clearly understand the physician (PA) profession, a literature database search was conducted, which yielded 86 dissertations awarded between 1972 and 2001 that included PAs in the title or abstract. The degrees awarded are predominantly PhD (70%) and EdD (22%). State-based universities awarded 70%; 8 universities awarded one third of the degrees. The topics of PA-focused dissertations are wide-ranging and include history, economics, education, organization, and behavioral research. This data set provides a source of information for future scholars.
Hughes N. Should you add a PA or an NP to your practice? Medical Practice Management. Jan/Feb 2005:203-206
Physicians and office managers have long sought solutions to enhancing medical care while controlling costs. One answer is to hire a physician assistant (PA) or nurse practitioner (NP). But which provider is best for the practice? There is no universal staffing solution. It depends on the needs of the patients, the needs of the practice, and the needs of the physician. All three factors should be part of the decision-making equation. This article raises the important questions that should be addressed when deciding whether a PA or an NP is the appropriate provider to add to the staff and offers recommendations on where to go to learn more about both professions to assist a practice in making a decision.
Hutchinson L, Marks T, Pittilo M. The physician assistant: would the US model meet the needs of the NHS? British Medical Journal. November 24, 2001 ; 232:1244-7.
Summary Points: Physician assistants make a major contribution to provision of health care in the United States. They function as "mid-level" practitioners, along with doctors in training and nurse practitioners. They train and work in a biomedical model and do not perform "nursing" tasks or tasks of other therapists. Introduction of US-style physician assistants in the United Kingdom would reduce medical staffing difficulties but would not help to remove professional boundaries or barriers to expanding scope of practice. It is not known whether introduction of another healthcare career pathway would attract into the health service people who would not have joined professions with poor recruitment.
Issa J. Are ON physicians ready for more assistants? National Review of Medicine. Dec 15 2007; 4(20). www.nationalreviewofmedicine.com/issue/2007/12_15/4_patients_practice05_20.html.
Jasser MZ. Mid-levels: The demise or the salvation of medicine. Arizona Medicine. Nov/Dec 2004:21,26.
Jones PE , Hooker RS. Physician assistants in Texas. J Texas Medicine. 2001; 97(1): 68-73.
Kaissi Am, Kralewski J, Dowd B. Financial and Organizational Factors Affecting the Employment of Nurse Practitioners and Physician Assistants in Medical Group Practices. J Ambulatory Care Manage. July-Sept. 2003, 26(3): 209-216.
Summary: This study examines the financial and organizational factors that are associated with the employment of nurse practitioners (NPs) and physician assistants (PAs) in medical group practices. The source of the data is a survey of 128 medical group practices in Minnesota . The findings suggest that the employment of NPs and PAs and their ratios to primary care physicians (PCPs) in practices that employ them are influenced by the organizational characteristics of the group practice but not by the degree of financial risk sharing for patient care. Although neither the number of years of experience in financial risk sharing nor more revenue from capitation payment contracts were related to employment of these midlevel practitioners (MLPs), large practices, those located in rural locations, not-for-profit practices, and those that scored low on cohesive cultural traits were more likely to employ MLPs. The data provide insights into the market for MLPs and the potential for these clinicians in the future health care system. As medical group practices become larger and have more organizational capacity, they can likely be expected to increase the employment of MLPs and integrate them into their organizations.
Kalin B. Clearing the Record on Physician Assistants. (Letter to the editor). Skin & Aging. April 2000; 13-14.
Keenan T. Support of Nurse Practitioners and Physician Assistants. To Improve Health and Health Care, Vol. II, 1998-1999, Chapter 11.
Kimball BA, Rothwell WS. Physician Assistant practice in Minnesota. Minnesota Medicine. May 2008. www.minnesotamedicine.com/CurrentIssue/ClinicalKimballMay2008/tabid/2551/Default.aspx
Abstract: Physician assistants (PAs) practice medicine with physician supervision, which allows physicians to see more patients and concentrate their efforts on the needs of those with complex medical conditions. Physician assistants have been practicing in Minnesota since 1970. They work in a variety of settings and specialties, although most are in primary care practices. This article profiles the PA profession and describes the type of work PAs do, the training and credentialing required to become a PA, and the relationship between physicians and PAs.
Kindig DA. PAs in a reformed health care system. JAAPA. Editorial, June 1994; 7(6):391-2.
King WB. The Benefits, Risks and Economics of Hiring a PA. Dermatology Business Management. January 2004: pp. 39-43.
Knott P, LaBarbera D. Physician Assistants: Partners in the Practice of Medicine. Hospital Physician. March 2000: 67-73.
Larsson LS, Zulkowski K. Utilization and Scope of Practice of Nurse practitioners and Physician Assistants in Montana. Journal of the American Academy of Nurse Practitioners. April 2002; 14(4):185-190.
Purpose: To explore the licensing, certification, governance and education requirements of nurse practitioners (NPs) and physician assistants (PAs) in the state of Montana . Services provided and privileges retained in employment were also analyzed. Data Sources: This was a descriptive study using a survey of rural hospital administrators (N=34). Conclusions: Survey results show that 92.5% of PAs in Montana meet their supervision requirement by a telephone contact provision outlined by the state board of medicine. In contrast, 54.2% of NPs, who are autonomous be legal definition, have a telephone supervision requirement imposed on them by their employers. Implications for Practice: These findings have implications for the current and prospective professionals and the businesses for which they work. Nurse practitioners and their professional organizations need to consider the implications these findings have on the professional image and marketability of all NPs.
Michener L. The rise of midlevel providers. Duke Medical Center News. June 2002; http://news.mc.duke.edu/news/controversy.php?id=5910.
Mittman DE . PAs and NPs: Explaining Rxs with a PA or NP signature. U.S. Pharmacist. 27(10): www.uspharmacist.com/index.asp?show=article&page=8_964.htm.
Mittman DE , Cawley JF, Fenn WH. Physician Assistants in the United States. BMJ. August 31, 2002:485-7.
Summary Points: Physician assistants are interdependent semi-autonomous clinicians practicing in partnership with physicians, and are found in almost every medical and surgical specialty. They perform similar tasks to their physician partners, including examination, diagnosis, diagnostic testing, treatment (including referral), and prescribing. research shows them to be capable of giving care comparable to that of physicians for similar services. Physician assistants have improved access to health care for populations in rural, inner city, and other medically underserved areas. With their training modified as needed to integrate with local health systems, physician assistants are a viable alternative to physicians in areas with shortages of doctors, such as the United Kingdom.
National Academy of Sciences Board on Medicine. New members of the physician's health team: physician's assistants. May 1970; 14pp.
Nurse Practitioners, PAs & Certified Nurse Midwives in California. Office of Statewide Health Planning & Development & Center for California Health Workforce Studies. U. of CA, San Francisco. Spring 2000.
Pagano MP. A PA by any other name is still a PA [letter, comment]. JAAPA. Jan 1994; 7(1):65-66.
Paniagua H, Stewart A. Medical care practitioners: introducing a new profession into the UK. British Journal of Nuring. 2005;14(7):405-408.
Abstract: The NHS is suffering from a serious shortage of qualified medical staff. One possible solution is to introduce medical care practitioners (MCPs) (USA-style physician assistants) into the healthcare team. This article examines the history and role of PAs, as well as some of the issues concerning the role, and how other health professionals might perceive it. The article also describes one MCP programme that has already started in Britain at Wolverhampton University. The use of MCPs in the UK appears to offer a potential solution to reduce the current skill shortage in this country.
Pilla L. Getting a focus on physician extenders. Skin & Aging. Nov. 2003;52-59.
Rosenoff E, Coffman J, Mertz E, Grumbach K. Nurse Practitioners, Physician Assistants and Certified Nurse Midwives in California . Report. Office of Statewide Health Planning and Development, Sacramento, CA and the Center for California Health Workforce Studies at the University of California San Francisco, 2000.
Ross N, Parle J. Physician assistants: a UK perspective on clinical need, education and regulation. Clinical Teacher. 2008;5:28-32
Runy LA. Filling the gaps: physician assistants and nurse practitioners see expanded roles and responsibilities. Hospitals & Health Networks.
Schneider ME. More PAs Heading Into Physicians' Office Practices. Family Practice News. November 15, 2003 ; 33(22).
The Scope of the physician assistant outlined. West Virginia Medical Journal. March/April 2001; 97(2):122.
Strand J. Anticipating the profession's future. JAAPA. October 2002; 15(10):51-54.
Abstract: This article considers the future of the physician assistant (PA) profession in light of trends in the US health care system. A bright job outlook is highlighted, and potential new professional roles are discussed. The author predicts opportunities for PAs in health care administration and entrepreneurship, syndromic surveillance and other public health efforts, and health workforce research, among other areas. PAs will be ideal proponents of new models of patient care, particularly with regard to helping health care consumers navigate the changes that will occur as a result of ongoing genetic discoveries. PAs' communication abilities, accessibility to patients, and socialization as team members make them well suited for these new roles.
Strickland G. Physician extenders: Which one is right for you? Applied Radiology. August 2005:23-28.
With the continued growth of imaging, an increasing number of radiologists are turning to physician extenders. The American College of Radiology's Task Force on Human Resources estimated that the workload for radiologists is increasing 6% each year while the number of radiologists is rising only 2% per year. Radiology departments and practices realize that if they are unable to meet the demand, other specialties will move to absorb the volume. Radiology practices have the option of hiring many types of physician extenders in their attempts to meet this demand. The most frequently utilized are physician assistants (PAs), nurse practitioners (NPs), radiology practitioner assistants (RPAs), and radiologist assistants (RAs). Each of these can act as a physician extender, but each is unique in terms of qualifications, scope of practice, malpractice coverage, and/or the ability to bill for his/her services. This manuscript will provide a description for each type of physician extender, their utility, and their limitations.
Sweet M. Side by side: Can physician assistants help rural doctors? Australian Rural Doctor. April 2008.
Walpert B. How to integrate a midlevel into your practice team. ACP-ASIM Observer. Jan. 2002.
Walpert B. Is it time for your practice to add a midlevel provider? ACP-ASIM Observer. May 2000.
What Training Do PAs Have? Psychiatric News. 38(13):5. July 4, 2003 .
White GL. Physicians, PAs and the Facts. Journal of the Mississippi State Medical Association. December 1997; 38(12):460.
White GL, Davis AM. Physician Assistants as Partners in Physician-Directed Care. Southern Medical Journal. October 1999; 92(10):956-960.
Abstract: 1998 marked the acceptance of Physician Assistants (PAs) as members in the Southern Medical Association. We review the history of the PA profession and, more importantly, the physician/PA relationship. We also provide an overview of PA education and certification requirements. Variations in state law regarding PA utilization, including the delegation of prescribing privileges, are discussed. Current American Medical Association guidelines regarding physician/PA practice are provided.
Wilson D, Pryor C. Adding mid-level practitioners to a group practice. Group Practice Journal. July/Aug. 2000:47-51.
Wing P, Langelier MH, Salsberg ES, Hooker RS. The Changing Professional Practice of Physician Assistants: 1992 to 2000. JAAPA. January 2004; 17(1):37-49.
Abstract
Background: Substantial changes in professional practice for physician assistants (PAs) occurred between 1992 and 2000. This paper describes a new professional practice index for the PA profession for 2000 that reflects current practice environments more accurately than did an index developed to reflect practice environments in 1992. In addition, the paper examines the relationships among the profession, its professional environment, and physicians, as well as the relationship between the PA profession and access to care for underserved populations. Results: Comparisons of the 1992 professional practice index for the PA profession and indices for 2000 indicate that, collectively, the scope of practice of PAs increased significantly across the United States over the 8-year period. Variation of the index scores narrowed over the same period, suggesting that the 1990s were a period of convergence of professional practice across the 50 states. During this period the numbers of practicing PAs nearly doubled between 1992 and 2000, and in 2000 there were 5.8 practicing PAs per 100 physicians in active patient care in the United States. The professional practice index for the profession is positively correlated with the numbers of PAs per capita across the 50 states for both1992 and 2000. Conclusion: Enabling legislation for PAs has been enacted in all 50 states and the District of Columbia over a 3-decade period. A period of consolidation and convergence of statutes and policies over the 1990s suggests that American medicine has endorsed the role of PAs. In spite of these findings, almost one third of states continue to have limited or restricted statutes for PA practice, mostly in the area of reimbursement.
