Team Approach to Health Care Delivery

THE PHYSICIAN – PHYSICIAN ASSISTANT TEAM

BY MICHAEL G. CLARK, PH.D., PA-C, AND SAMUEL T. COLERIDGE, D.O.

Michael G. Clark, Ph.D., PA-C; is an assistant professor of physician assistant studies in the Department of Family Medicine at the University of North Texas Health Science Center.

Samuel T. Coleridge, D.O., is a professor in the Department of Family Medicine at the University of North Texas Health Science Center and he is soon to be inducted as president of the Texas Academy of Family Physicians.

Teamwork is a concept necessary for any physician practice setting. Each day physicians depend on individuals of various educational backgrounds to assist them in making health care delivery possible for their practice populations. The team ranges from the receptionist who greets the patient, to the medical assistant or nurse who prepares the patient for examination to the tech who performs the EKG, or draws blood or … well the list goes on. The physician of today, and of the future, recognizes the need of the “team” to meet the dynamic demands of today’s health care environment.

An excellent example that epitomizes the team relationship, especially in Texas, is the physician-physician assistant team concept. After four decades, physicians have increasingly incorporated the skills of PAs as extensions of their practices and as members of the health care team. (1, 2) In the physician-PA team model, the PA is delegated medical acts by the supervising physician. In doing so, the PA becomes an “extension” or “agent” of the supervising physician. This physician-PA team model is an interdependent relationship that recognizes the physician as the team leader. Today the physician-PA team can be seen in all disciplines of practice. (1, 3) Even though most PAs are trained and practice in the primary care medical disciplines, an ever-increasing number are being utilized in the medical and surgical subspecialties. (1)

As defined by the American Academy of Physician Assistants, the physician assistant is a skilled health care professional who provides medical care through the supervision of a physician. (1) Trained as clinical partners, the philosophy and socialization of the PA profession is one of providing medical services as directed by and in collaboration with the supervising physician. (1, 2, 4) No matter the autonomy delegated by the supervising physician to the PA, the physician still remains the manager of health care delivered through the physician-PA team. (1, 4, 5)

History of the Physician-PA Team
The physician assistant profession was established by physicians and university educators in the mid-1960s to assist physicians in meeting the growing health care needs of communities throughout America, especially those with little or no health care support. This need was even more apparent with the initiation of health care systems such as Medicare and Medicaid. The first PAs were Vietnam War medics and corpsmen returning home with significant medical experience but no place to utilize their skills. One of the founders of the PA profession, Dr. Eugene Stead, at Duke University recognized these individuals as the perfect students to enter his brand new training program entitled the “Physician Assistant.” (2)

From those first four students at Duke, there are now over 50,000 PAs in practice nationwide including over 3,000 PAs in Texas. PAs are licensed to practice in every state, the District of Columbia, Guam, the Virgin Islands, and Puerto Rico. They serve as commissioned officers in the uniformed services and the U.S. Department of Public Health. PAs practice in other federal settings such as the Veterans Administration, the State Department, and the federal prison system. (6) PAs from each branch of the military are assigned as medical officers to the White House.

Education of the Physician Assistant
Physicians, PAs and other educators at over 130 accredited programs nationwide train PAs. (7) In Texas there are eight PA programs including the uniformed services inter-service PA program based at Fort Sam Houston in San Antonio. The typical student entering into a PA program has at least four years of college and four years of health care experience or exposure. The intensive and comprehensive PA curriculum is patterned after the “medical model,” focuses on general primary care medicine, and is approximately 24 to 31 months in length with a mean of 27 months. (7) The curriculum consists of classroom and laboratory studies in the basic medical and behavioral sciences in courses such as anatomy, pathophysiology, microbiology, psychology, pharmacology, epidemiology, physical examination, clinical medicine, preventive medicine and physical diagnosis. After completion of the didactic instruction, the PA student must complete 12 to 15 months of structured clinical clerkships in physician-PA team settings including family medicine, internal medicine, pediatrics, obstetrics and gynecology, geriatrics, emergency medicine, surgery, orthopedics, and psychiatry. (8) Most PA programs across the country and in Texas grant a master’s degree or offer a master’s degree option upon completion but some programs grant other degrees and diplomas. No matter what the degree or diploma the program grants, all PA programs must meet the same rigorous accreditation standards established by the Accreditation Review Commission of Education for the Physician Assistant. (7, 8) The ARC-PA is the only accreditation body for PA educational programs and is comprised of representatives from the PA educator and PA profession community, the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians and American Medical Association.

After successful completion of the curriculum, the student is eligible to take the national board certification examination administered through the National Commission on the Certification of the Physician Assistant. The NCCPA board and test writing staff include representatives from the PA profession, American Academy of Physician Assistants, AMA, AAFP and the American College of Surgeons.

To be licensed in Texas, one must be a graduate of an accredited PA program and have passed the NCCPA examination. To maintain licensure in Texas, the PA must obtain at least 40 hours of continuing medical education annually. To maintain the NCCPA certification the PA must complete at least 100 hours of continuing medical education every two years and must satisfactorily pass the recertification examination every six years. The Texas State Board of Physician Assistant Examiners, a board within the Texas State Board of Medical Examiners, is responsible for licensure and professional oversight of the PA profession. Supervision and licensure information as well as Texas statute and rules for PA practice can be accessed at www.tsbme.state.tx.us.

Skills and Utilization of the Physician Assistant
In most practice settings, supervising physicians may delegate a medical responsibility to a PA that they feel the PA is trained and capable to deliver. (1, 2, 4) In general, physician assistants are trained to perform history and physical examinations, order and interpret laboratory and radiologic studies, develop a working diagnosis, implement a treatment plan, repair lacerations and remove minor lesions, apply a splint or cast, provide patient education, provide counseling in preventive medicine, initiate a consult and prescribe medication. (1, 4, 17) In addition to clinical functions, PAs are often utilized as health educators for practice settings, providing enhanced patient compliance and satisfaction.

Physician-PA teams can be found in outpatient and inpatient settings in every discipline. According to the 2002 AAPA census, approximately 50 to 55 percent of PAs were employed in primary care practice settings such as family practice, general internal medicine, pediatrics, OB/GYN and geriatrics. (6) Close to 20 percent are in practice in general surgery and surgical subspecialties such as orthopedics, cardiovascular surgery, neurosurgery, and plastic surgery. (9) Approximately 15 percent of PAs practice in medicine subspecialties such as cardiology, rheumatology, endocrinology and dermatology and over 10 percent of PAs practice in emergency medicine and occupational medicine. Physicians in medical and surgical specialties utilize the PA educational base as a resource for entry-level clinical duties into the discipline as well as excellent preparation for expanded clinical training.

Texas PAs tend to track similarly as the national trends with approximately 50 percent of PAs practicing in primary care physician-PA teams. (6, 17) In Texas the majority of rural health clinics are staffed by PAs and many more PAs provide health care in medically underserved areas of Texas. Under federal and state laws, the physician has more options for utilizing PAs in areas that are considered medically underserved.

Even though most physician assistants work in the outpatient setting, the 2002 AAPA census states approximately 40 percent of PAs in practice have some type of hospital practice responsibilities. (6) Examples of some of the basic responsibilities that PAs may assume in this setting include first-assistant coverage for the daily and emergent operating schedule; evaluating patients in the emergency department for traumatic and surgical problems; performing history and physical evaluations; conducting daily patient rounds; gathering and evaluating patient data, evaluating changes in a patient’s condition; issuing orders for admission and discharge, medications, treatments and laboratory tests; and writing or dictating discharge summaries. (10) Many hospitals hire PAs to function as house staff for surgical or medical departments, in emergency departments or in intensive care units. (10, 11)

PA Productivity and Liability
Physician-PA teams enhance the delivery of health care because PAs are trained as productive, clinical partners in physician-directed medical care. (12) PAs can provide care that will allow physicians to shift their workloads and priorities as well as allow for more flexibility. Ideally the PA assumes more of the routine medical duties such as acute care, non-illness care, and routine chronic care allowing the supervising physician to concentrate on more complicated cases. (12, 13) This allows the physician-directed practice setting to run more efficiently and productively. (13)

PAs provide quality, productive health care with high patient satisfaction. One example of this is the AMA’s Socioeconomic Monitoring System survey, which in 1994 measured the benefits of employing “non-physician practitioners” (NPPs) including physician assistants, nurse practitioners, clinical nurse specialists and certified nurse-midwives. The survey found that solo practice physicians utilizing NPPs experienced expanded practice, greater efficiency and greater access to care for their patients. Physicians who employed NPPs were able to work one week less per year on average, while supplying more hours in office visits and patient care, and increasing their individual net income by nearly 18 percent. Of the four NPP groups in the study, PAs rated highest in terms of patient productivity and patient acceptance. In a 1997 study, Kaiser Permanente Center for Health Research found patient satisfaction levels with physician assistants rated highly. Aspects of patient satisfaction examined by the study included interpersonal care, confidence in provider, and understanding of patient problems. (13)

PAs have been shown to be productive, cost-effective health care professionals. Medical services provided by PAs are covered under Medicare, Medicaid, Tricare/Champus and most private insurers. As for productivity, according to the Medical Group Management Association’s 2000 Physician Compensation and Production Survey, PAs generate revenues covering far more than what their compensation costs employers. (13)

One important question that is commonly asked, is whether PAs increase or decrease liability. It is clear that effective and timely communication with patients greatly lowers the risk of a malpractice suit. As stated before, one of the productive qualities of utilizing PAs include enhancement of communication and increased time with patients’ especially complex cases.

Information from the National Practitioner Data Bank reveals that PAs incur a remarkably low rate of malpractice judgments. Moreover, other data support the possibility that hiring a PA may reduce the risk of malpractice liability. As changes in health care delivery force shorter patient visits and other restraints on care, one hopes that PAs’ traditional strengths as excellent clinicians and communicators will continue to validate a conviction expressed early in the history of the profession by the AMA’s assistant general counsel who stated: “PAs probably hold the potential for being one of the best malpractice tools available ...” (Brock, R. The Malpractice Experience: How PAs Fare. AAPA Practice Brief, June 1998). (14)

Summary
Physician Assistants are cost-effective, productive health care providers delivering quality health care in the physician-directed team. The physician-PA team concept is a philosophy to which PAs are committed and socialized in training and in practice. These concepts were recognized in the 1995 AMA House of Delegates. (4, 15, 16) This team approach has allowed physicians more flexibility, efficiency and productivity in their practices. (16) For more information on the physician-PA team and the PA profession the following online sites are provided: American Academy of Physician Assistants at www.aapa.org, Texas Academy of Physician Assistants at www.tapa.org, or the Texas State Board of Medical Examiners/Texas State Board of Physician Assistant Examiners at www.tsbme.state.tx.us.

References
1. Cawley JF. “The Profession in 2002 and Beyond.” Journal of the American Academy of Physician Assistants, (15):7-15, 2002.

2. White GL, Davis AM. “Physician Assistants as Partners in Physician-directed Care.” Southern Medical Journal, (92):956-960, 1999.

3. American Academy of Physician Assistants. “Physician Assistant Facts at a Glance.” www.aapa.org/glance.html. Accessed 14 Dec. 2002.

4. American Academy of Physician Assistants. “Physician Assistant Scope of Practice.” www.aapa.org/gandp/scope-practice.html. Accessed 15 Dec. 2002.

5. Aparasu RR, Hegge M. “Autonomous Ambulatory Care by Nurse Practitioners and Physician Assistants in Office-based Settings.” Journal of Allied Health, (30):153-159 2001.

6. American Academy of Physician Assistants. “2002 AAPA Physician Assistant Census Report.” www.aapa.org/research/02census-intro.html. Accessed 14 Dec. 2002.

7. Glicken A. “PA Education in an Evolving Health Care System.” Journal of the American Academy of Physician Assistants, (15):16-26, 2002.

8. American Academy of Physician Assistants. “Physician Assistant Education.” www.aapa.org/edinfo.html. Accessed 15 Dec. 2002.

9. Condit D. “Opportunities and Challenges in the Surgical Subspecialties.” Journal of the American Academy of Physician Assistants. (15):40-42, 2002.

10. American Academy of Physician Assistants. “Physician Assistants in Hospital Practice.” www.aapa.org/gandp/hospital.html. Accessed 16 Dec. 2002.

11. Miller W, Riehl E, Napier M, et al. “Use of Physician Assistants as Surgery/Trauma House Staff at an American College of Surgeons-verified Level II Trauma Center.” The Journal of Trauma, Injury, Infection, and Critical Care. (44):372-376, 1998.

12. Larson EH, Hart LG, Ballweg R. “National Estimates of Physician Assistant Productivity.” Journal of Allied Health. (30):146-152, 2001.

13. American Academy of Physician Assistants. “Hiring a PA: The Benefits for Physicians and Practices.” www.aapa.org/gandp/hiringPA.html. Accessed 15 Dec. 2002.

14. American Academy of Physician Assistants. “The Malpractice Experience: How PAs Fare.” www.aapa.org/gandp/pamalpct.html. Accessed 16 Dec. 2002.

15. Davis A. “Putting State Legislative Issues in Context.” Journal of the American Academy of Physician Assistants. (15):16-26, 2002.

16. Wolk B. “Physician Assistants Prove Professional Assets.” Michigan Medicine. (50):52, 1997.

17. Cawley JF. “Physician Assistants.” Journal of the American Medical Association. (13): 1094, 1997.