Emerging Role of the Physician Assistant
THE EMERGING ROLE OF THE PHYSICIAN ASSISTANT IN THE MEDICAL FIELD
Abstract.
The physician assistant (PA) profession was established in the early 1960s in response to expanding medical needs and patient demand for more accessible doctors and treatment. The pioneer of the physician assistant profession laid the groundwork for the profession's growth into the global position it is today. In the United States, PAs are now licenced in every state, and recent health care reform under the Affordable Care Act has raised demand for PAs, creating a climate conducive to the further growth of the PA profession. PAs will continue to expand doctors' reach in the present and future as the ever-increasing medical demands of patients grow more difficult to meet properly. The PA's position has already expanded significantly, and as the medical sector progresses, the PA's role and need will continue to grow and adapt.
Introduction
Over the last few decades, the healthcare industry has continued to grow in terms of inpatient load, people, and new treatments and technology. 1 Throughout history and to the present day, doctors and other medical professionals have often struggled to keep up with ever-increasing patient demand. 1 As a result of doctors' incapacity to care for a rising number of patients, the Physician Assistant, or PA, was born. 2 The PA profession has changed and developed in a variety of ways since its inception. Several of these advances include the following: 1) a significant improvement in public and other healthcare professionals' perceptions of the PA profession; 2) a rise in the number of persons pursuing the profession; and 3) a shift in the area of practise and specialisation. 3 The notion of an advanced care professional, which includes Physician Assistants and Nurse Practitioners, has grown across the United States and even into other nations. 4 A more recent development that has had a significant influence on the PA profession and the whole health care area is health care reform. 5 With the recent introduction of the Affordable Care Act (ACA), generally referred to as "ObamaCare," doctors anticipate a major increase in the number of patients they treat, resulting in an increased need for physician assistants. 6 In the near and far future, physician assistants are projected to continue to play a critical role in assisting doctors in providing the best possible care to their patients. Indeed, the physician assistant job has expanded significantly since its inception, a trend that is certain to continue as the medical industry expands and advances.
General History:
In 1961, a physician called Charles Hudson coined the term "advanced care professional." 1 Hudson submitted a paper in the Journal of the American Medical Association on the rising medical field's need for "non-professional employees." 2 Not until later was this intended occupation dubbed the medical assistant. Hudson predicted that as the United States' population grows, there will be an increase in hospital visits by patients, forcing medical personnel, particularly physicians, to spend an increasing amount of time in the hospital setting and an increasing amount of time with individuals receiving home or office visits. 2 At the time, there were a variety of strategies for dealing with the expanding patient population. However, these tactics were ultimately ineffective, prompting Hudson to publish the essay described before. Prior to the 1960s, the medical community responded to increasing patient numbers by increasing the number of medical student interns and residents working in hospitals, rotating hospital staff through different areas of the hospital, hiring medical residents or physicians to live in the hospital to oversee the emergency department and perform after-hours hospital duties, constructing physician offices within the hospital, and placing m 2
Hudson sought an alternate approach after becoming aware of the difficulties presented by these tactics.
He proposed and specified two new professional categories, one for "non-medical" workers and another for "non-nursing" personnel.
2 These people, according to his proposal, would offer normal medical care to patients, relieving doctors of their duty. The physician in charge of non-medical workers was required to establish their scope of practise, since they were effectively a "extension of the doctors' arms, legs, and brains." 1 Hudson modelled this support workers after military corpsmen. Corpsmen got less education than doctors and were in charge of troops' health during war. 2 Hudson believed that, as a result of the military model's success, it was equally conceivable to employ someone with less medical expertise than a physician efficiently in a civilian health context. 2 Dr. Hudson's vision did not become a reality until four years later.1
Dr. Eugene A. Stead, Jr. of Duke University in North Carolina was also conscious of the country's growing physician deficit, particularly in rural regions, and when he became chair of the university's Department of Medicine, he formed a vision for improving health care in the state. 1 Dr. Stead established the first official training programme for "non-medical" individuals in 1965, dubbed the Physician assistant programme (PA). 1 Dr. Stead worked with Thelma Ingles, the supervisor of Medical and Surgical Nursing at Duke University Nursing School, prior to joining the Department of Medicine and establishing the new programme, in 1957. Dr. Stead persuaded Ingles to take a year off to study different procedures at the medical school, which was new for a nurse. 1 Ingles returned from her sabbatical year and developed a Master of Science in Nursing programme based on her medical school experience.
Unfortunately, the programme was never certified by the National League for Nursing, and hence collapsed. Stead used the failure of the MS nursing programme to generate interest in the physician assistant programme he would eventually establish in 1965. 1
Figure 1. Picture of Dr. Eugene A. Stead. Dr. Stead was the founder of the Physician Assistant Profession and organized the first training program at Duke University in North Carolina in 1965.7
Dr. Stead developed the PA education curriculum after conducting an examination of various connections and models in the medical field. 1 For instance, one of these individuals was Dr. Amos Johnson, a well-known physician from North Carolina. Dr. Johnson travelled often, and to ensure that his patients' needs were met while he was gone, he employed an assistant called Buddy Treadwall. Buddy Treadwall was responsible for providing basic medical treatment and patient referrals when Dr. Johnson was abroad. 1 Dr. Stead also conducted research on Dr. Henry McIntosh, a cardiologist at Duke University. Dr. McIntosh was having difficulty recruiting personnel for the cardiac catheterization laboratory in the early 1960s. He contacted the local fire department in an attempt to resolve his issue. Dr. McIntosh offered to teach the firefighters in emergency medical techniques in return for their time in the laboratory, allowing them to better serve the community. Dr. Stead established the programme and carefully chose the first recruits based on these and other examples. 1
Dr. Stead's programme was administered by Duke University's Department of Medicine and was completely separate from the Duke Nursing School and Hospital Administration.
1 He structured the curriculum to last two years, with the first nine months devoted to academic understanding and the remaining to clinical experience. Students gained knowledge of diagnostic and therapeutic approaches, as well as how to operate ancillary equipment used in patient care. Similarly to medical interns, PA students rotated through several hospital settings, and at the conclusion of the programme, they chose an area of personal interest to practise in. 1 Initially, the initiative targeted mainly males, especially military corpsmen who were returning from Vietnam and presumably looking for civilian work. With many hours of special education and on-the-job training under their belts, Stead reasoned that these guys were ideal candidates for the medical assistant programme. 1 Stead anticipated that the first physician assistants entering the job would meet criticism; he required individuals capable of overcoming hardship, such as the corpsmen, to ensure the program's success. Dr. Stead's goal throughout the program's development and introduction was to guarantee that physician assistants function as an extension of the physician, unable to flourish without the direction of a physician. Dr. Stead provided two options for the PA in order to reach this goal: "The PA may gain independence while maintaining a low level of performance, or he can accept reliance while maintaining a high level of performance." From the inception, the physician assistant profession was intended to complement, not to diminish, the physician's role.1
Physician Assistant Early Years:
Dr. Stead faced intense criticism after the program's development, primarily from the American Nurses' Association (ANA). 1 The ANA protested five years after the programme was established that the new profession was founded by the American Medical Association.
The American Medical Association (AMA) is attempting to undercut the ANA's attempts to isolate nursing from medicine. Coincidentally, nurses were also developing a new identity during this time period, since they no longer wanted to be known to patients as the "physician's handmaiden." 1 Another facet of the new profession that irritated the ANA and the nursing community was the fact that the majority of PAs were male and paid the same, if not more, than officially trained nurses. Although the dispute between the two huge health care groups clouded the waters for the new, burgeoning physician assistant profession, the ANA's assertions were false. The AMA had considered the prospect of teaching health care workers, such as nurses, to undertake advanced clinical care ten years prior to the foundation of the new profession. 1 It was as a result of these previous internal conversations.
Dr. Stead sensed a need to create the physician assistant profession, which he communicated to the AMA.
1 Soon after the Duke University programme enrolled its first students, it garnered widespread notice and exposure, resulting in a two-hundred candidate pool by the program's second year. 1 However, Look magazine ran a storey headlined "More than a Nurse, Less than a Doctor" in 1965, against Duke University's desires. 1 This essay raised the possibility of reigniting the latent but pre-existing friction between the nursing community and the newly formed physician assistant profession. To combat the bad press, Dr. Stead worked tirelessly to secure the medical community's backing of the new profession. This was a challenging assignment, since doctors had varied sentiments about the profession at the time. For example, some questioned how a somebody with a fraction of their educational experience could assist a physician, while others questioned how the intimate physician-patient connection would alter with the inclusion of the PA. Finally, doctors were concerned about whether the advantages of hiring a PA would offset the higher insurance coverage expense. Dr. Stead utilised the then-current nurse shortage to show the repercussions of expected future physician shortages, which eventually helped doctors overcome their reservations. He reminded doctors that if they did not support the PA profession, future risks would be unknown. 1 With time and experience working with PAs, doctors gradually reacted positively and accepted the new profession. According to Dr. Stead's initial vision, doctors moulded physician assistants into their current positions, which resulted in the profession's improved acceptance.1
As a consequence of the notoriety surrounding Duke University's PA programme, numerous additional such programmes around the United States were discovered.
1 For example, Fort Bragg had established a curriculum for corpsmen that trained them to undertake medical services on military facilities without direct medical supervision. Additionally, another programme at the University of Washington in Seattle trained corpsmen. They were, however, educated in this programme to assist areas in need of more comprehensive medical treatment. The University of Colorado was educating paediatric nurse practitioners and clinical nurse specialists. While Dr. Stead endorsed these initiatives, he believed that the PA profession provided greater value to the person and patient than these other programs.1
Due to early differences between the American Medical Association (AMA) and the American Nursing Association (ANA), there has been ongoing conflict, impeding these two organisations' capacity to operate effectively together.
1 The AMA made numerous further efforts to recruit nurses to train as medical assistants; however, the ANA and other nursing organisations refused these offers, questioning if nurses would gain anything by relinquishing their identity to become physician assistants. They said that such a move would compel them to relinquish their right to operate independently of doctors. 1 At this time, the ANA supported the physician assistant profession, but not its recruitment of nurses. Finally, the ANA's refusal to recognise the new profession cost the organisation and its members money, accumulating a sizable deficit between 1970 and 1972. Despite the tensions and public disagreements between the ANA and the AMA, the physician assistant programme continued to develop in size and power, and by 1972, there were around 20 distinct programmes located across the United States. 1
Dr. Stead had several challenges during his early years in the field, one of which was obtaining AMA certification for his programmes.
1 The AMA continued to see the profession as "experimental" four years after the programme began. 1 However, as a result of Dr. Stead's tenacity and determination, the AMA eventually adopted a pro-physician assistant attitude, paving the way for a hopeful future for the PA profession. 1 Duke University's programme was certified for the first time in September 1972. 8 The regulating body established for the purpose of accrediting PA programmes is currently called as the Accreditation Review Commission.
The Commission on School for Physician Assistants, Inc., or ARC-PA, is a subsidiary of the American Medical Association that took over accreditation of PA education programmes on January 1, 2001.
8,9 Prior to 2001, the accrediting governing body changed hands regularly. Initially, the American Medical Association's Council on Medical Accreditation was in charge of accreditation.
Education. In 1976, the Committee on Allied Health of the American Medical Association
The Commission on Accreditation of Allied Health Education Programs (CAHEA) became the regulatory body in 1992, followed by the Commission on Accreditation of Allied Health Education Programs (CAHEAP) in 1994. (CAAHEP).
9 Today, the United States has a total of 199 recognised programmes, a figure that has continued to expand. 8
As previously indicated, early rivalries between the medical and nursing professions hampered physician assistant adoption across the United States.
10 However, as tensions abated and the profession evolved, PA programmes spread swiftly throughout the United States, increasing interest in the new profession and expanding the role of the PA. Notably, there were two significant periods of substantial expansion in the number of PA programmes in the United States. The first occurred between 1970 and 1974, in response to increasing government funding for the programme and profession. 10 Between 1994 and 2000, the second wave of expansion resulted in a near-doubling of the number of programmes in the United States (see Figure 2). Another noteworthy period of expansion was qualitative rather than quantitative. In 1986, the vast majority of PA programmes provided solely bachelor degrees, with just 28% providing associate's degrees or certificates.
As is the case now, there were few programmes at the time that culminated in a master's degree. By comparison, just 14.3 percent of colleges and universities continued to provide an associate's degree or certification in 2000, while 42.9 percent continued to offer a master's degree. 10
Fig. 2. Growth trends of the PA Program in the United States between 1976 and 1999. The number of PA programs experienced significant growth during two notable periods, from
1970-74 and from 1994-2000.10
Another notable qualitative change was the increase in specialty options. The early physician assistants only provided primary care specialties for patients. However, following the growth of the 1990s, most PAs gained the responsibility of prescribing medications and new opportunities for specialties emerged.10 By 2000 surgical and medical subspecialty positions became available to PAs and the profession had spread to every state.10 Also notable is that within a five year period the number of trained PAs more than quintupled in size by 2000. In addition to these achievements in the PA profession by 2000, the number of PAs in urban areas was only slightly higher than in rural areas, thus close to accomplishing one of the original goals of the new profession, namely to supply PAs to rural areas of the country.10 The increase in specialization opportunities for PAs beyond primary care led to increased job opportunities from the 1980s and to date. It is estimated that in the year 1974, almost 70% (68.8%) of PAs were in primary care. This number changed drastically in the years that followed and by 2000 only 47.8% of PAs were in primary care and the most commonly sought after areas were in internal medicine subspecialties, emergency medicine and surgical subspecialties.10
Physician Assistant Present Day:
Today, the role of the physician assistant has continued to expand with time.11 Although the scope of practice of PAs depends on the USA state in which they are employed, their level of experience, and specialty, in general PAs are licensed in all 50 states and are allowed to perform a variety of medical tasks, including documenting medical history, performing physical exams, diagnosing and treating illnesses, ordering and analyzing tests, developing care and treatment plans, advising patients on preventative care, assisting in surgery, writing prescriptions, and performing rounds in the hospital, as well as in the nursing home setting. PAs are commonly involved in inpatient medicine and the largest employer of PAs today is the Veterans Health Administration (VHA).3 The inpatient procedures performed at the VHA and other settings are similar. However, one major difference is that PAs working for the VHA are under federal jurisdiction and therefore can bypass state legislation as far as the scope of practice is concerned, thus allowing them, in certain instances, more flexibility and freedom.3 It is clearly evident that the scope of practice for PAs has drastically expanded over the years beyond inpatient medicine.12 Today, PAs are commonly employed in the Emergency Department, helping to decrease the patient load on both physicians and surgical residents. PAs have also been approved to work in fields, such as pediatrics, trauma, orthopedics, and thoracic and cardiovascular surgery. The current outlook of the usability of PAs in a growing number of medical fields is a positive one.12
In addition to the changing role of the PA, the education training programs for PAs has also adapted.11 The program, originally designed to be two years, is mostly now a 26month or a 3 academic year program and each graduate is awarded a Master’s degree. In addition to the in-class instruction, there is a minimum of 2,000 hours of clinical rotation required. Rotations include hours spent in family medicine, internal medicine, obstetrics and gynecology, pediatrics, general surgery, emergency medicine, and psychiatry. After graduation from a PA program, the new graduates are then expected to take the Physician Assistant National Certifying Exam or PANCE, an exam administered by the National Commission on Certification of Physician Assistants or NCCPA. In order for the new graduates to receive state licensure the PANCE exam must be passed. The final step of becoming a PA in the United States is maintaining certification, which is achieved by completing 100 hours of continual medical education every two years and completion of the
Physician Assistant National Recertifying Exam every 10 years.11
As the education and role of the physician assistant has progressed, the profession has sought more specialized positions in healthcare.13 Today the most common specialties for PAs are urgent care, dermatology, emergency medicine, cardiothoracic surgery, neurosurgery, orthopedic surgery, obstetrics and gynecology, neurology, and gastroenterology. Of these, Urgent Care is considered to be the highest paid specialty and obstetrics and gynecology is the lowest.13 It is common for PAs to change specialties at least once throughout their career.14 The training program involved in PA specialization is a residency program, making it easy to change specialties in comparison to the specialization process of physicians. The program on average lasts 12 months and usually has only two students per cycle. There are currently 41 PA residency programs that are members of the Association of Postgraduate Physician Assistant Programs in the United States. However, more programs are presently being developed. Additionally, PAs can be specialized in cardiovascular and thoracic surgery, emergency medicine, nephrology, orthopedic surgery, and psychiatry through the CAQ system. In this system, PAs must pass an exam specific to their desired specialty in order to practice. In the future, it is predicted that PAs will continue to expand the list of specializations they practice and thus the PA profession and education system will continue to grow.14
Differences of Scope of Practice between States:
As the acceptance of the physician assistant increased across the United States, the position and training programs spread to all 50 states.15 National governing bodies continue to oversee PA education and training programs in all states.9 The current governing body for PA education training programs took over the accreditation process in 2001 and is the Accreditation Review Commission on Education for the Physician Assistant. The second national governing body involved in PA education is the National Commission on
Certification of Physician Assistants. This group oversees the certification of PAs through an exam known as the PANCE.9
Today, each individual state is responsible for the regulation of the scope of practice of the physician assistant.9 It is the desire of the AAPA, or American Academy of Physician Assistants to have the roles of the PA standardized. However, the states have not yet generated a standardized scope of practice. State laws and regulation determine the various aspects and extent of PA practice, including general supervision, the scope of practice, authority to issue prescriptions, discipline, and the creation of regulatory agencies to oversee these issues (see Appendix One). Supervision determines the number of PAs that an allopathic physician (MD) or osteopathic physician (DO) can oversee at any given time. The MDs and
DOs are the only two medical professionals who are authorized to assume supervisory responsibilities over PAs, and they must be licensed to practice in the state that the PA is working. Supervision of a PA differs from the employment of a PA, thus a PA can be the employer of their supervising physician.9 The second aspect that is regulated at the state level is the scope of practice of the PA. The scope of practice of a PA determines the extent or scope to which the PA can practice under a supervising physician, while being as reasonable and practical as possible. Many states elect for the supervising physician to determine the scope of practice of their PAs. Individual states decide whether or not to allow PAs to sign for physicians in their absence when that task is delegated by their supervising physician. Prescribing authority is also determined at the state level.9 This determines what medications and what quantities physician assistants are allowed to both prescribe and administer to patients. Each individual state has the authority to implement their own regulatory agencies that are responsible for the governing of the state laws and discipline, if ever necessary. Such an arrangement and independence in state regulation of the PA profession creates differences in standards. However, there are also similarities across states in the U.S. Nonetheless, overall, the lack of standardization of the PA profession across states makes it difficult to have national standards for the profession.9
There are only thirteen states that do not allow the physician assistants to have full prescriptive authority.15 Some of these thirteen states do not allow PAs to prescribe schedule II medications, i.e., medications most likely to be abused. These states include Alabama,
Florida, West Virginia, and Hawaii and others. No state in the Northeast United States limits PA prescriptive authority. Iowa is the only state that does not allow PAs to prescribe any schedule II depressants and Kentucky is the only state that does not allow PAs to prescribe or administer scheduled drugs.15
There are thirty-five states that allow the PA and their supervising physician to build a written agreement that determines the scope of practice for the PA.15 The other fifteen states regulate the scope of practice of the PA at the state level through state medical boards.
There are ten states where the law specifically outlines the services that a PA can provide.
These states include Florida, Iowa, New Jersey, Ohio, Oklahoma, Pennsylvania, Virginia, Maryland, Washington, and Wisconsin (see fourth column of Appendix 1). This category has an almost 50-50 split between states. Half of the states feel that state law should govern supervision requirements so that a responsible supervisory path is established. The other half allows each individual practice or medical setting to determine the supervisory path.15 Finally, the number of PAs that a single physician can supervise can greatly impact the overall practice as a whole. The average number of PAs that a physician can supervise at any given time is 3.65.15 The national median figure is four, with the highest number in Texas at seven PAs per supervising physician. However, there are eleven states that do not specify the maximum number of PAs that a physician can supervise. Nonetheless, there are exceptions to the number of PAs a MD or DO can supervise at any given time. For instance, in New York a physician may supervise up to six PAs at any given time in a correctional facility. In Ohio, the maximum number of PAs allowed per physician can be greater in a hospital setting. In West Virginia a physician is allowed to supervise four PAs in a hospital setting in comparison to three PAs outside of the hospital.14 It is hoped that one day, in the near future, a common standardized system will be adopted across all state lines.15
Public Perception:
The public perception of the physician assistant has played a critical role in the development of the profession. At first the profession was met with controversy and resistance from patients and doctors. However, over the course of years the perception of PAs has drastically changed for the better. For instance, in 1972, when the profession was still in its infancy and growing, a study was conducted to assess the public perception of physician assistants in rural Iowa and Minnesota.20 The study addressed the public’s acceptance of the new profession and asked what roles the physician assistant should be allowed to occupy. In general, the study found that the public accepted the new profession but was divided over the duties a PA should be allowed to perform.20 Two-thirds of those interviewed stated that they would allow a physician assistant to provide extended care for them and their families when the individual providing the care was adequately trained. In addition to training, the individuals who completed the study also expressed that they would only allow a physician assistant to attend to them if their primary care physician recommended and supported the PA.20 The study also found that 34% of the rural people in Minnesota and Iowa were uncomfortable with a PA performing an initial screening prior to seeing a physician. In contrast, 83.23% of the individuals were in support of physician assistants offering referrals to patients to determine where they should seek treatment.20 A more recent study, performed in 2013, found that people continually preferred to see a physician over the physician assistant or other advanced care professional.21 However, if they could be provided care faster by a PA, the patient chose the PA over waiting longer for a physician. This study also found that 82.5% of the people who took the survey knew what a physician assistant was, therefore, showing that the public has a better understanding of the PA today than they had in previous years.21 Another interesting statistic from the study showed that 81.4% of the survey respondents had been seen by a physician assistant prior to taking the survey. However, slightly over half of the people (50.3%) still preferred to be seen by a physician when available. Interestingly, women and younger adults were more likely to have been seen by a physician assistant than older males and whites were less likely to have been seen by a physician assistant compared to other ethnic groups. Overall, the study found that Americans were open to the idea of physician assistants and other advance care professionals having a greater role in healthcare.21 As the medical field becomes more reliant on advanced care professionals such as physician assistants, it is important to consider the patients perception on PAs. It is anticipated that as the number of PAs increase, patients will become more exposed and therefore familiar and knowledgeable about the new profession.21
Globalization of the Physician Assistant:
The shortage of physicians is a global trend and recently many countries are now turning to the U.S. PA model to resolve and mitigate the shortage.4 For this reason, there has been a steady globalization of the PA profession and by 2007 at least seven countries had either already employed or began to train PAs, including Australia, Canada, England, the Netherlands, Scotland, South Africa, and Taiwan (See Figure 3). In all of these countries, except South Africa and Taiwan, the PA functioned similarly to the roles practiced in the United States. In both South Africa and Taiwan, American-trained PAs worked independent of doctors and were involved in developing educational programs to train health care providers. Much like the U.S., the United Kingdom (UK) seeks PAs to help reduce the workload of physicians. Over the years the challenges faced by the UK health care system has resulted in increased wait times for patients, an increased desire for providers to specialize, and an increased workload on physicians.4 Similar to the UK and other countries, the PA profession was introduced in Canada due to physician shortages and the inability to provide adequate healthcare for its citizens. Australia’s major challenge has been providing adequate care to citizens in rural areas. As a result, physician assistants have been employed to help serve these communities. The Netherlands is currently experiencing an increasing number of elderly individuals and an increase in healthcare costs. With the introduction of the PA, the Netherlands hopes to improve caregiver-to-patient ratios and reduce health care costs. The truth is that the USA PA model in health care is not a novel idea. Countries such as Russia, the Ukraine, China, Malaysia, Zambia and others have developed PA-like professions to improve health care.4
Figure 3. Depiction of the Countries across the world who currently employ Physician
Assistants. These seven countries are Australia, Canada, England, the Netherlands, Scotland,
South Africa, and Taiwan. 4
For now, the critical mass of PAs are in the U.S.16 As of 2013, the U.S. employs at least 84,855 PAs compared to Canada and the UK that only employ 250 and 165, respectively. Canada, like the United States, developed their PA programs from the military. However, they follow a different process in employing PAs. In Canada, a physician seeking to employ a PA must apply for a grant from the government and present evidence on the need of the PA. This process makes the employment of PAs in Canada difficult, thus contributing to the low number of practicing PAs. The UK system was not established until 2003 after a group of twelve experienced PAs performed a pilot project in England. As a result of the success of the program, four training programs were erected. As the United States, Canada, and the United Kingdom continue to support the growth of the PA profession, it is expected that the PA profession will continue to experience globalization and offer an efficient addition to the health care system in many countries.16
Anticipated Impact of Health Care Reform on PA Profession:
Health care reforms have occurred several times throughout the history of the United States and will continue to do so as new societal challenges arise. The most recent and perhaps most influential health care reform in recent times was signed into law in 2010 and is still in the phase of implementation.6 This health care reform is known as the Patient
Protection and Affordable Care Act, more commonly as the Affordable Care Act, or “Obamacare,” as cited earlier. The implementation of this reform has been controversial in both politics and health care.
The main objective of the Affordable Care Act (ACA) is to expand coverage of care to the general citizenry by providing health insurance to individuals of a lower socioeconomic class that previously were not able to afford insurance.17 The bill guarantees affordable health care for all Americans and plans to provide a better environment for health care professionals, such as physicians and advanced care professionals. The bill is intended to provide patients with more available information about physicians and treatment options. For health care professionals, legislatures anticipate the bill to implement strong incentives that improve quality and reliability of patient care, while capping the increasing cost of health-related procedures. The ACA promotes and incentivizes preventative practice and intervention testing, in order to avoid readmissions and secondary prevention measures. The bill also supports the training of advanced care professionals so that they may one day join the primary care sector of health care. In order to address the decrease in primary care professionals, the ACA has offered a 10% payment bonus to qualifying individuals who are practicing primary care to encourage individuals to seek the primary care sector.17 The major controversy of the ACA involves the cost of program implementation. Some politicians, health care professionals, and American citizens have voiced disagreement with various aspects of the health care plan.
With the increased availability of health care to uninsured citizens, who are largely of a low socioeconomic background, it is anticipated that there will be an increase in the number of patients seeking care, thus leading to a significant increase in demand for primary care providers.6 For instance, it is estimated that 8.5 to 22.4 million people will join a
Medicaid program in order to gain access to health care. As a result, approximately 4,500 to 12,100 new health care providers will be needed in the primary care setting to reach the new demands. 6 As the shortage of physicians continues to grow, reaching its critical point in 2025 when the baby boomer generation reaches an age that will require more medical attention, the services of the PAs will especially become crucial. It is estimated that an additional 40,000 health care professionals will be needed by 2025 to care for these indivdiuals.6 Predictive models suggest that with the current growth of the PA profession coupled with the growth of PA training programs across the country, by the year 2025 there will have been a 72% increase in the number of practicing PAs.19 The recent trend shows the decrease in the number of physician assistants choosing primary care is not expected to be a major issue in meeting the growing need of primary care physicians. It is predicted that there will be a significant increase in the number of physicians or advanced care professional to offset the exodus of PAs from primary care. However, it is important to note that with the anticipated 72% increase in the number of practicing physician assistants, it will only provide 16% of the total providers required to adequately care for the baby boomer generation.19 Consequently, the role of the physician assistant will continue to evolve as it is shaped by various forces, one of which being Health care reform.19
Concluding Remarks:
The physician assistant profession has significantly evolved since its inception in 1965 at Duke University and has spread into different aspects of health care. It appears that the greatest beneficiaries have been the patients, who have overall been welcoming and appreciative of the incorporation of the PA in the medical field. The PA profession also has had a significant impact on the other health care professionals, including nurses, physicians, and advanced care professionals and is now a force to reckon with even in health care politics, to the extent that the PA profession was recognized as an important player in the recent health care reforms. This recent development will likely catapult the PA program into the biggest growth it has ever experienced before. However, challenges still remain. There are still patients that are reluctant to receive care from a physician assistant. It is expected that this mentality will change with time as integration of the PA in health care accelerates and as the patient demand increases across the globe. PAs will likely be in the frontlines while continuing to provide their historical role of extending the physicians reach to patients.
Bibliography:
<![if !supportLists]>1. <![endif]>Holt N. "Confusion's Masterpiece": The Development of the Physician Assistant
Profession. Bulletin of the History of Medicine. 1998;72 (2):246-78.
<![if !supportLists]>2. <![endif]>Hudson CL. Expansion of Medical Professional Services with Nonprofessional
Personnel. The Journal of the American Medical Association. 1961;176 (10): 839-841.
<![if !supportLists]>3. <![endif]>Kartha A, Restuccia JD, Burgess JF, Benzer J, Glasgow J, Hockenberry J, et al. Nurse practitioner and physician assistant scope of practice in 118 acute care hospitals. Journal of Hospital Medicine. 2014;9 (10)
<![if !supportLists]>4. <![endif]>Hooker RS, Hogan K, Leeker E. The Globalization of the Physician Assistant
Profession. The Journal of Physician Assistant Education. 2007;18 (3):76-85.
<![if !supportLists]>5. <![endif]>Britt LD, Hoyt DB, Jasak R, Jones RS, Drapkin J. Health Care Reform. Annals of
Surgery. 2013; 258 (4): 517-526.
<![if !supportLists]>6. <![endif]>Dow AW, Bohannon A, Garland S, Mazmanian PE, Retchin SM. The Effects of Expanding Primary Care Access for the Uninsured: Implications for the health Care
Workforce Under Health Care Reform. Journal of the Association of American
Medical Colleges. 2013; 88 (12): 1855-1861.
<![if !supportLists]>7. <![endif]>Carter R. Dr. Eugene A. Stead, Jr. MD. Physician Assistant History Society; http://www.pahx.org/stead-jr-eugene, 2016
<![if !supportLists]>8. <![endif]>Accredited PA Programs. 2016; http://www.arc-pa.org/acc_programs/, 2016
<![if !supportLists]>9. <![endif]>Guidelines for State Regulation of Physician Assistants. American Academy of
Physician Assistants. 2011.http://www.aapa.org/workarea/downloadasset.aspx?id=795
<![if !supportLists]>10. <![endif]>Larson EH, Hart LG. Growth and Change in the Physician Assistant Workforce in the
United States, 1967-2000. Journal of Allied Health. 2007; 36 (3):121-130.
<![if !supportLists]>11. <![endif]>Become a PA. 2016; http://www.aapa.org/Become-A-PA/, 2016
<![if !supportLists]>12. <![endif]>Victorino GP, Organ, Jr CH. Physician assistant influence on surgery residents.
Archives of Surgery. 2003;138 (9):971-976.
<![if !supportLists]>13. <![endif]>Santiago AC. Physician Assistant Specialities and Salaries. 2014.
http://healthcareers.about.com/od/compensationinformation/tp/physician-assistantspecialties-and-salaries.htm
<![if !supportLists]>14. <![endif]>Glicken AD, Miller AA. Physician Assistants: From Pipeline to Practice. Academic
Medicine, 2013; 88 (12): 18883-1889.
<![if !supportLists]>15. <![endif]>Physician Assistant Scope of Practice laws. The Henry J. Kaiser Family Foundation.
2014. http://kff.org/other/state-indicator/physician-assistant-scope-of-practice-laws/
<![if !supportLists]>16. <![endif]>Gerrie BJ, Holbrook EA. The Evolutionary Role of Physician Assistants across the United States, Canada, and the United Kingdom. Interantional Journal of Exercise Science. 2013; 6 (1): 1-8.
<![if !supportLists]>17. <![endif]>Kocher R, Emanuel EJ, DeParle NM. The Affordable Care Act and the Future of Clinical Medicine: The Opportunities and Challenges. Annals of Internal Medicine.
2010; 153: 536-539.
<![if !supportLists]>18. <![endif]>McDonough JE. The Road Ahead for the Affordable Care Act. New England Journal of Medicine. 2012; 367: 199-201.
<![if !supportLists]>19. <![endif]>Hooker RS, Cawley JF, Everett, CM. Predictive Modeling the Physican Assistant
Supply: 2010-2025. Public Health Reports. 2011; 126 (5): 708-716.
<![if !supportLists]>20. <![endif]>Litman TJ. Public Perceptions of the Physicians’ Assistant- A Survey of the Attitueds and Opinions of Rural Iowa and Minnesota Residents. American Journal of Public
Health. 1972; 62 (3): 343-346.
<![if !supportLists]>21. <![endif]>Dill MJ, Pankow S, Erikson C, Shipman S. Sruvey Shows Consumers Open to a Greater Role for Physician Assistants and Nurse Practioners. Health Affairs. 2013; 32
(6): 1135-1142.
Table One. Differing Physician Assistant Laws by State.
United States | Full Prescriptive Authority: | Scope of Practice determined on site: | Adaptable Supervision Requirements: | Maximum Number of PAs a Physician can Supervise at One time: |
AL, FL | No | No | No | 4 |
AK, MT, NM, NC, TN | Yes | Yes | No | N/A |
AZ, CA, DE, MI, NH, NY, OR, SD, UT, DC, | Yes | Yes | Yes | 4 |
AR | No | Yes | No | N/A |
CO | Yes | Yes | No | 4 |
CT | Yes | Yes | Yes | 6 |
GA | No | No | Yes | 4 |
HI | No | Yes | Yes | 2 |
ID, NV | Yes | Yes | No | 3 |
IL, MN | Yes | Yes | Yes | 5 |
IN | Yes | Yes | Yes | 2 |
IA | No | No | No | 5 |
KS, NE | Yes | Yes | No | 2 |
KY, OK | No | No | No | 2 |
LA | No | Yes | No | 2 |
ME | No | Yes | Yes | N/A |
MD | Yes | No | Yes | 4 |
MS, PA | Yes | No | No | 2 |
MO | No | Yes | No | 3 |
NJ, OH, SC | Yes | No | No | 4 |
ND, RI, VT, MA | Yes | Yes | Yes | N/A |
TX | Yes | Yes | Yes | 7 |
VA | Yes | No | No | 6 |
WA | Yes | No | Yes | 5 |
WV | No | No | No | 3 |
WI | Yes | No | Yes | 2 |
WY | Yes | Yes | Yes | 3 |
Appendix One.
Name of person completing questions: Elizabeth Wynja PA, Fast Med Urgent Care, Boone, NC
Date: 2/26/16 Questions:
<![if !supportLists]>1. <![endif]>Throughout the years have you changed your perception on Physician Assistants? Honestly, not really. I've always viewed us as physician extenders – to allow for the role of physicians to be expanded in an economical way, rounding out a physician's services. This may be manifest as a physician assistant working on-site with his/her supervising physician, working a tightly-defined limited role, or serving more of an independent comprehensive-care role with his/her supervising physician available by phone for consult. I guess I did not realize the scope of practices a physician assistant could take on – we can serve in just about any role a physician can. Our supervising physician tells us how far we can go!
<![if !supportLists]>2. <![endif]>Throughout the years have you noticed a change in the Patient’s perception of Physician Assistants? Maybe because I am a physician assistant, people have spoken very highly of physician assistants in my presence. Patients seem very comfortable seeing a mid-level provider for their medical needs and oftentimes prefer mid-level provider care because we generally have more time to spend with our patients. There have been a few that feel we provide inferior sub-optimal level care, but these are rare, and they generally change their opinions after they have received care by a physician assistant.
<![if !supportLists]>3. <![endif]>Throughout the years have you noticed a change in your Coworkers’ perception of the Physician Assistant? If anything, I feel like my coworkers have become more comfortable with seeing Physician assistants for medical care, after they have witnessed the care we provide.
<![if !supportLists]>4. <![endif]>Do you think that the creation of the PA position has made a positive impact on the medical field? In what ways? PAs are able to provide cost-effective care, they are able to work in all fields of medicine, they are able to relieve care burden/share care burden with physicians, they are able to fill voids when there are physician shortages, and they oftentimes are able to serve an educator's role and thus enhance patient experience and therefore potentially patient well-being due to having more time to spend with patients.
<![if !supportLists]>5. <![endif]>Do you think that the creation of the PA position has made a negative impact on the medical field? In what ways? PAs do not in any way impinge upon medicine, in how it is provided today. They provide quality care without any threat to those in medicine with higher degrees.
<![if !supportLists]>6. <![endif]>How do you expect the role of the PA in the medical field to change in the future? I would expect even more physicians to expand their practices to include more PA services, and for PAs to take on even more comprehensive and specialized roles in the future.
<![if !supportLists]>7. <![endif]>How has recent health care reform changed the outlook of the PA profession, if any? Do you expect it to change the role of the PA in the future? With ever-increasing emphasis on more economical health care, I expect to see more and more PAs providing services that physicians would otherwise provide in all specialties.
Appendix Two.
Name of person completing questions: Kathy Benge RN, Fresenius Medical Care at Novant
Health Rowan Medical Center, Salisbury, NC Date: 2/23/2016 Questions:
<![if !supportLists]>1. <![endif]>Throughout the years have you changed your perception on Physician Assistants?
When I first started going to the doctor many years ago, I don’t even remember hearing the term “physician assistant”. I have only in recent years begun hearing the term and actually interacting with them both personally and professionally. At first, I did not see them as professionals but just as doctor’s assistants and assumed that everything they said and did came straight from the doctor they were assisting. It wasn’t until I took the time to listen and work with them did I start to view them as professionals who were capable of treating myself and the patients I took care of.
<![if !supportLists]>2. <![endif]>Throughout the years have you noticed a change in the Patient’s perception of Physician Assistants?
What I have witnessed through my patients is that they have become much more accepting of the PA’s role as they have come to get to know them and have more interactions with them. They also seem to be more accepting of the PA when they are presented to them by their own doctor. I have some patients that prefer the PA’s to the doctors because they seem to “listen better” and take more time with them. However, there are still those few patients who only want to see their doctor and do not take the time to consider the value of a PA.
<![if !supportLists]>3. <![endif]>Throughout the years have you noticed a change in your Coworkers’ perception of the Physician Assistant?
My Coworkers perception of the PA has become much more respectful as they have worked beside them in various roles in the medical field. For the most part, they are treated with the same respect given a doctor. Depending on the age of my coworker, the younger ones are much more at ease with the PA’s because they have always been around than some of the older nurses who have tons of experience and remember a time when there were no PA’s.
<![if !supportLists]>4. <![endif]>Do you think that the creation of the PA position has made a positive impact on the medical field? In what ways?
<![if !supportLists]>I <![endif]>feel the creation of the PA position has made a positive impact on the medical field as it allows someone to come in and learn under the guidance and experience of a seasoned medical doctor. That doctor can pass on the knowledge they have gained from their own mistakes and their successes to their PA to take and grow further. It also gives more patients the benefit of having 2 medical minds working with them.
<![if !supportLists]>5. <![endif]>Do you think that the creation of the PA position has made a negative impact on the medical field? In what ways?
<![if !supportLists]>I <![endif]>wouldn’t necessarily say it has made a negative impact but I am sure medical school applications are down due to the high cost of education since its creation. However, I do have some reservations that someone with pretty much any college degree and some patient care hours can apply to PA school and become a PA in 2 years. I do feel more medical education and experience would be appropriate.
<![if !supportLists]>6. <![endif]>How do you expect the role of the PA in the medical field to change in the future?
<![if !supportLists]>I <![endif]>expect it to see it continually grow and expand into even more medical specialties. In recent years, I have witnessed its continual steady growth and added acceptance by patients and coworkers alike.
<![if !supportLists]>7. <![endif]>Concluding remarks: I believe the PA positon is an awesome career path for the up and coming new generation. I believe the opportunities will be endless and am excited to see where it will lead in the near future. I am biased because I am in the medical field but I find it so interesting and uplifting.
Credit: H. J. McCune
.webp)
No comments: