With physicians and housestaff in short supply, physician assistants help fill the coverage gaps
From the October ACP Observer, copyright © 2005 by the American College of Physicians.
By Janet Colwell
Laurie Witcher, PA-C, a 25-year veteran physician assistant (PA) at Seattle's Virginia Mason Medical Center, has a simple way of explaining to patients the difference between a PA and a general internist: The PA is a dictionary, while the doctor is an encyclopedia.
"When it comes to the basic things that you do everyday—like vaccinations and prescription refills—the dictionary is just fine," said Ms. Witcher, one of two PAs working in the general internal medicine section at Virginia Mason, a multispecialty group practice with close to 400 physicians and more than 30 PAs. "But when patients need more information, that's where the more extensive training of the internist comes into play."
For Joyce K. Lammert, ACP Member, an allergist at Virginia Mason, working with a PA means she can concentrate on more complex cases.
"Rather than go home at the end of the day totally beat because you've seen between 40 and 50 patients, you feel you've done a great job," Dr. Lammert said. "You've seen more interesting patients and done more of what you were trained to do."
For a growing number of practices and hospitals across the country, hiring PAs is making financial as well as clinical sense.
For a growing number of practices and hospitals across the country, hiring PAs is making financial as well as clinical sense. Last year, ACP recognized the growing importance of PAs by creating an affiliate membership category for fellows of the American Academy of Physician Assistants (AAPA), the only national PA membership association. So far, the College has signed on about 50 affiliate members.
Growth in the health care industry as a whole is driving the demand for PAs, especially in hospitals and in specialty areas experiencing physician shortages. Even in areas where physicians aren't scarce, PAs can help improve both patient care and a practice's bottom line.
Joyce K. Lammert, FACP (left), and physician assistant Laurier Witcher review a patient's chart. Dr. Lammert finds many advantages for patient care in teaming up with physician assistants.
"Reimbursement certainly won't be going up in the future and costs aren't going down," observed Dr. Lammert, who pointed to business models—like Kaiser Permanente's—that rely on health care teams. "It's very clear that if [the team approach] is done right, it increases the number of patients you see and probably improves the care you deliver."
Primary care and beyond
The PA profession was created in the 1960s at Duke University in Durham, N.C., by the late Eugene A. Stead Jr., MACP, then chair of Duke's department of medicine. Dr. Stead, the first recipient of the College's Distinguished Teacher Award in 1969, envisioned the PA's role as supporting overworked primary care physicians, especially in underserved rural areas.
Forty years later, PAs have become a mainstay of rural health care. In Winnfield, La. (population 6,000), for example, Tony Acosta, PA-C, oversees care at Winn Parish Medical Center's specialty clinic. Along with providing primary care services in partnership with internist Mark V. Shelton, FACP, Mr. Acosta helps run the outpatient cardiac rehabilitation clinic. (See "A winning team helps bring AEDs to rural community.")
In most states, what a PA can or cannot do is determined by a supervising or sponsoring physician or medical group. All states allow PAs to take call, while only two states—Indiana and Ohio—do not allow PAs to write prescriptions. (See "PA fast facts.")
In a practice, PAs typically take on more responsibilities as their relationship with sponsoring physicians matures. Seattle's Ms. Witcher, for example, now independently provides a complete menu of primary care services, routinely handling general physical exams, women's health care, sports medicine and infectious diseases. She also coordinates care for patients with chronic diseases such as diabetes and hypertension, writes prescriptions, admits patients to the hospital, and handles outpatient follow-up visits.
That's an indication of how far the profession has evolved over 40 years, said Richard C. Rohrs, PA-C, AAPA president, who worked as a PA for more than 20 years before assuming his current job as director of hospital medicine at Northwest Hospital Center in Randallstown, Md.
"Early on, I remember having to go to our medical executive committee and ask for PAs to be able to write change-diet orders on patients," Mr. Rohrs recalled. "Now, PAs are running our anticoagulant service, taking care of high-risk problems and following up on surgical patients. What we did when we started is barely a fraction of what we do now."
Hospitals and specialization
According to the AAPA, 55,061 PAs were working in clinical practice at the beginning of 2005—a 36% increase since 2000.
While primary care is still the career choice of many PAs, a growing number are choosing specialties. Of PAs responding to the 2004 AAPA census, 42% reported working in the primary care fields of family medicine (30%), general internal medicine (8%, down from 8.5% in 2001), obstetrics/gynecology (3%) and general pediatrics (3%). Between the 2001 and 2004 census, the number of PAs working in primary care fields dropped from 48% to 42%—while the number working in non-primary care fields and primary care subspecialties rose from 52% to 58%.
At least 61 specialty fields were represented in that census, including general surgery and surgical subspecialties (24%), emergency medicine (10%) and internal medicine subspecialties (10%). Among internal medicine subspecialties, most went to cardiology (3.3%), gastroenterology (1.6%) and hematology/oncology (1.4%).
"We are now seeing a huge shift in PAs going to academic health systems, surgery and surgical subspecialties, and hospitals," said Justine Strand, PA-C, associate clinical professor and chief of the physician assistant division at Duke University.
At Northwest Hospital Center where he works, Mr. Rohrs said that hiring PAs has been helpful in attracting and retaining attending physicians. The medical center merged its PAs with its hospitalist service and now has one PA on staff for every 20 beds.
And in Hempstead, N.Y., Hofstra University saw a number of its PA graduates hired to work exclusively in hospitals, said Stanley A. Shanies, FACP, a Long Island cardiologist and medical director of Hofstra's PA program, which graduated its first class in December 2004. Many of Hofstra's PA graduates were hired by nearby Long Island Jewish and North Shore University hospitals, which are affiliated with the Hofstra program.
According to Dr. Shanies, PAs are increasingly stepping in as hospitals struggle to comply with new resident work hours mandated in 2003 by the Accreditation Council for Graduate Medical Education. When the revised rules went into effect, hospitals were "calling physicians to come within 30 minutes of admission and write physicals and orders," said Dr. Shanies. Adding PAs "has really freed up physicians."
And in response to physician shortages, training programs are developing postgraduate PA tracks. According to Dr. Shanies, Hofstra will launch a PA certificate program in critical care for certified PAs at the end of this year.
The one-year program, done in partnership with Long Island Jewish Hospital, will allow students to earn credits toward a master's degree and train them to work in critical care settings, including surgical and respiratory intensive care and coronary care units. Hofstra is also considering establishing a postgraduate surgery track for PAs.
"Part of what prompted this is that there is a shortage of critical care physicians and we need more clinically trained PAs to fill that gap," Dr. Shanies said. "The ICU should be covered 24 hours a day by trained people. At present, that isn't possible because housestaff is limited in the number of hours they can work and the number of patients they can follow."
Hurdles and payoffs
In office-based practices, advocates say one reason to hire a PA vs. another physician is the salary differential—in 2004, according to the AAPA census, a full-time PA made an average of $78,257—and lower malpractice premiums. Even more significantly, physicians who work with PAs point to the productivity and efficiency they can add to a practice.
John F. Strandmark, ACP Member, worked with two PAs for almost 15 years while he was part of a group practice in Lansing, Mich. Hiring PAs solved two major problems for the busy practice, which gradually grew into a multispecialty group with 30 physicians: It improved patient access, and it allowed the group to take on another panel of patients at a nearby nursing home where Dr. Strandmark was medical director.
"The PAs saw people with emergent problems," said Dr. Strandmark, who three years ago went into solo practice in the Lansing suburb of Okemos. "That improved quality of care because people got into the office the same day they called with a problem." For the physicians, he said, the payoff was a less crammed schedule. "Instead of seeing four or five work-ins over the course of a day, we just saw the people on our schedule."
In addition to improving access and reducing pressure on physicians, however, having PAs also created an unintended consequence: The PAs began developing their own panel of patients who were rarely if ever seen by their physician.
"That's not good because even in the best setting the physician's eyes are different from the PA's eyes," he said. "I was going longer than I felt comfortable without seeing some of my patients. The physician doesn't need to see a patient on every visit—but it's important that we remain actively involved in each patent's care."
Productivity was also an issue, he said. Because they were on a set salary, the PAs tended to take too much time with patients who came in for lower level problems, such as upper respiratory or urinary tract infections. PAs, just like physicians, also sometimes code visits at a lower level than warranted by the documentation, he said.
For physicians who want to hire a PA, Dr. Strandmark suggested adding productivity incentives to the PA's compensation package. Still, he said, "the access they provided our patients was enough to outweigh the disadvantages."
Another issue to consider before hiring a PA is the time spent in training—and the possibility of lost revenue. It typically takes several months or more working closely with a physician before PAs can see patients on their own.
Dr. Lammert at Seattle's Virginia Mason, for example, spent six to nine months training the PA who works with her, who already had 15 years of experience before taking the job. While it was time-consuming, said Dr. Lammert, it wasn't much different from training other members of the staff. Besides, she said, the training period "helped develop the feeling of the team and got us on the same page."
As for patient comfort levels, most are at ease seeing a PA—although some longtime patients have reservations. "When I talk to patients, I tell them that we work together and they'll probably be seeing the PA if they have a less complex problem," said Dr. Lammert. "If you've had a relationship with a patient for a long time, they're less comfortable, but newer patients are usually fine with it."
Dr. Strandmark agreed that having PAs was a plus for new patients. "Who they saw was never a problem," he said. "What they liked more than anything was being seen in a timely fashion."
PA Fast facts
Training. PAs complete a two-year, nationally accredited program, one year of courses and another doing clinical rotations. Certification requires passing a test given by the National Commission on Certification of Physician Assistants. To maintain certification, PAs must log 100 hours of continuing medical education every two years and take a recertification exam every six years.
According to the American Academy of Physician Assistants (AAPA), the majority of PA students have a bachelor's degree and 45 months of health care experience prior to admission to a program. While all programs recognize the completion of the professional component of PA education with a certificate of completion, more than half the programs award a master's degree.
Postgraduate education. PA programs offer master's, bachelor's and associate's degrees. In 1988, eight postgraduate programs came together to form the Association of Postgraduate Physician Assistant Programs, dedicated to further specialty education for PAs. PAs can take postgraduate training in general surgery, orthopedic and cardiothoracic surgery, dermatology, emergency medicine, family medicine, hospitalist medicine, neurology, obstetrics-gynecology, oncology, pediatrics, psychiatry, pediatrics, rural primary care, and urology.
Prescribing. PAs are licensed by the state to practice. Forty-eight states, the District of Columbia and Guam have enacted laws allowing PAs to prescribe. Indiana and Ohio are the only exceptions.
Average income. $78,257 for full-time PAs and $64,536 for PAs in practice for less than one year, according to a 2004 AAPA census survey.
A winning team brings AEDs to rural community
Around the small community of Winnfield, La., Mark V. Shelton, FACP, and Tony Acosta, PA-C, are known as "Dr. Defib" and "Mr. AED." The monikers are an tribute to the physician-physician assistant (PA) team for bringing automated external defibrillators (AEDs) to rural Louisiana.
Shown here in their office, Mark V. Shelton, FACP (left), and Tony Acosta (right), have trained more than 3,000 volunteers to use AEDs.
That effort also resulted in national recognition: For their efforts, Dr. Shelton and Mr. Acosta received the American Academy of Physician Assistants' 2005 physician-PA partnership award, given to a team that can "provide greater medical service to their patients and their community than neither would be able to do working alone."
Their partnership began in 1987 when Dr. Shelton—who'd just set up practice as the town's only general internist—spoke to a group of emergency medical technicians (EMTs) about the need to put AEDs in town ambulances. Mr. Acosta, then a part-time EMT who taught math at the local high school, was among the first to sign on.
"He said that the town probably wouldn't ever get paramedics, so the next best thing we could do was to get AEDs," recalled Mr. Acosta, who is now a full-time PA at Winn Parish Medical Center. While Dr. Shelton lobbied political leaders, Mr. Acosta drummed up public support, raising funds and talking to civic organizations.
Within a year, state legislators passed a bill legalizing the use of AEDs by emergency medical technicians, and Winnfield's ambulance service became the first rural service in the state to use the device.
The project's success also launched Mr. Acosta on a new career. He trained as a PA at Louisiana State University Health Sciences Center in Shreveport, La., and has worked with Dr. Shelton for the past six years.
He is now Winn Parrish's clinical services manager, overseeing a specialty clinic that brings in orthopedic surgeons, cardiologists and anesthesiologists from nearby cities. He also helps manage inpatients at the nearby hospital, assists Dr. Shelton with primary care, and provides outpatient cardiac care rehabilitation and cardiac stress testing.
And he and Dr. Shelton continue their public service efforts. Their successful AED campaign led to the 1999 passage of a public access to defibrillation law in Louisiana, and the two have trained more than 3,000 volunteers in AED use and cardiopulmonary resuscitation. Mr. Acosta also helped convince state legislators to pass a law in 2004 allowing physicians to delegate prescribing authority to PAs.
As the town's only internist, Dr. Shelton said having a PA cuts down on his workload and provides a valued colleague. A PA is particularly helpful in a rural area, he added, where it is often difficult to recruit physicians.
"When you're in a solo practice like I am, often there are no other physicians to talk about cases with," he said. "Discussing cases with Tony allows me to think things out more clearly."
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