The Physician Assistant


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The Physician Assistant

  2. 2. Foreword W ith the printing of the 13th edition of The Physician Assistant, we at CAPA can look back and see the progress that our profession has made over the years. All those who came before us should be recognized, for it is because of their hard work we have matured to the great profession we are today. The Physician Assistant booklet is an excellent educational tool for those who want to learn about physician assistants and the critical role we play in the health care team. CAPA is here to fulfill our mission as stated below. The Mission of the California Academy of Physician Assistants is to represent and serve PAs statewide. As an advocate of its members for quality health care and for their valued, unique alliance with supervising physicians, CAPA will enhance, educate and empower physician assistants for the ultimate benefit of their patients.
  3. 3. The Physician Assistant History and Concept P hysician assistants provide medical, diagnostic and therapeutic services diabetes. Physician assistant practice is centered on patient care and may under the supervision of licensed include education, research and physicians. administrative activities. The supervising physician may delegate Physicians of any specialty may employ to the PA most medical services and a PA. Just as there are many kinds of duties that are routinely performed physician specialists, there are many within the normal scope of the kinds of PAs. physician’s practice and which the PA is competent to perform. The supervising physician has ultimate responsibility for the patient and supervision of the PA. The physician assistant concept was born during an era when primary care physicians were in short supply, particularly in rural and inner city areas. In 1965, in an effort to augment scarce medical care, Dr. Eugene Stead of Duke University established the first PA training program. He believed that, under the supervision of a physician, PAs could safely and effectively provide services previously provided solely by physicians. He was accurate in his vision. Today, there are 135 accredited PA programs and over 58,000 physician assistants nationwide. PAs perform a wide variety of medical and surgical functions, depending on their training, practice setting, and the needs of their supervising physician. In practice, most PAs routinely elicit complete medical histories and perform comprehensive physical examinations. They see patients with common acute problems such as infections and injuries. They do minor surgical procedures and provide ongoing care for common chronic problems such as arthritis, low back complaints, hypertension and
  4. 4. The Supervising Physician E very physician assistant must have a supervising physician. A PA may have and can assess first hand the ability and potential of a PA. Many preceptors multiple supervising physicians and a go on to hire PAs for their practice. supervising physician may supervise more Physicians wishing to become preceptors than one PA. or to locate qualified physician assistants for their practice should contact In California, “supervision” means the individual training programs or reviewing with the PA, as needed, either the California Academy of Physician directly or by electronic means, the Assistants. findings of the history and physical examination and the tasks performed by the PA. Supervision need not be given prior to treatment, nor must supervising physicians be on the premises as long as they are available by phone or other electronic means. The physician-PA team must establish, in writing, guidelines for timely supervision. They may be general or specific and may include standing orders, protocols, drug order guidelines, individual patient orders, emergency consultation guidelines, and chart review mechanisms. The physician has the responsibility of following the patient’s progress to ensure that the PA does not function autonomously. Very often physicians serve as preceptors for students in a physician assistant training program prior to employing a PA. As preceptors they become involved in the teaching process
  5. 5. Services PAs May Perform P As may perform tasks or services delegated to them by their supervising following appropriate training and demonstrated competency. Including but not limited to: physician. The scope of practice of the supervising physician determines the type  Biopsies of services rendered by the PA.  Lumbar punctures Medical procedures and tasks PAs may  Vein harvesting perform in California include, but are not  And many others depending limited to, the following: on specialty 1. Take a thorough history, perform an 5. Recognize and evaluate situations which appropriate physical examination and call for immediate attention of the primary make an assessment and diagnosis care physician and institute, when necessary, therefrom, and record and present emergency treatment procedures essential pertinent data in a manner meaningful to for the life of the patient. the physician. 6. Instruct and counsel patients regarding 2. Order or perform routine laboratory matters pertaining to their physical and and screening procedures including, but mental health, such as diets, social habits, not limited to, these examples: family planning, normal growth and  The drawing of blood and routine development, and the aging process. examination of the blood 7. Assist the physician in the institutional  Radiological studies setting by arranging hospital and nursing  Catheterization and routine home admissions, providing services urinalysis to patients requiring continuing care,  Nasogastric intubation and gastric including the review of treatment and lavage therapy plans, and by evaluating patients  Pelvic examinations, including and performing the procedures and tasks bimanual examinations and specified in subsections 1, 2 and 3 above. Papanicolaou smears. 8. Serve as first or second assistant in surgery. 3. Order or perform routine therapeutic procedures including, but not limited to, 9. Initiate and facilitate the referral of these examples: patients to the appropriate health facilities, agencies and resources of the  Injections community.  Immunizations  Debridement, suturing and care of 10. Administer or furnish medication, write superficial wounds a drug order or transmit an oral or written prescription for medication,  Strapping, casting and splinting of subject to certain limitations. sprains  Incision and drainage of superficial PAs are subject to the limitations set forth skin infections by their supervising physicians and to the policies of the employing institutions, 4. Order or perform many specialized in addition to the laws and regulations therapeutic and diagnostic procedures governing utilization of PAs in California.
  6. 6. Education and Certification Education: examinations, ordering and interpreting diagnostic tests, instituting therapeutic There are 10 accredited primary care plans, and patient education focusing on physician assistant programs in California preventive medicine. and 135 accredited programs throughout the country, most of which require 24- 48 months to complete. Many programs Examination: require applicants to have completed two Every new PA in California must pass the years of college prior to admission and to Physician Assistant National Certifying have previous health care experience. Examination (PANCE) administered by the National Commission on Programs are accredited by the Certification of Physician Assistants Accreditation Review Commission on (NCCPA). The examination is Education for the Physician Assistant comprehensive in scope and assesses (ARC-PA) based on quality standards academic and patient management deemed essential for PA education. knowledge. Most physician assistants nationwide are trained in broad based primary care, Certification: although there are PA specialists as well. PAs may maintain national certification by earning 100 hours of continuing medical Other California programs additionally education every two years, and are offer postgraduate training in orthopedic retested every six years by the NCCPA. and cardiothoracic surgery. Licensure: The education of PA students is similar to that of medical students in that a To practice in California, each PA must didactic phase of intense academic course be licensed by the Physician Assistant work is followed by supervised clinical Committee of the Medical Board of experiences or rotations. California. This requires submitting an official application and fees, proof of In the first year, students usually complete graduation from an approved program courses in such topics as anatomy and successful completion of the National and physiology, microbiology, physical Certifying Examination. diagnosis, pharmacology, common laboratory and screening techniques, common medical and surgical procedures, medical ethics, and a course in clinical medicine, among others. In the clinical phase, students apply the skills they learned during the didactic phase of training through rotations in primary care and specialty settings under the supervision of a physician. Training emphasizes eliciting complete patient histories, performing physical
  7. 7. Practice Settings P hysician assistants are employed in many specialties. A partial listing includes general hospitals, nursing facilities, intermediate care facilities, and private homes. and family practice; emergency medicine; pediatrics; obstetrics and gynecology; The granting of hospital privileges to surgery; orthopedics; geriatrics; women’s PAs is at the discretion of the individual health; occupational medicine; psychiatry facility. A booklet entitled, “Physician and mental health; cardiology and internal Assistants and Hospital Practice” is medicine; oncology; and administrative produced by the American Academy of research and educational fields. Physician Assistants and can be ordered from API at (703) 787-8044. California PAs practice in a variety of rural and urban settings, always under the supervision of a licensed physician. Typical practice settings include:  Solo and group practices  Health maintenance organizations  County facilities  Clinics  Hospitals  Hospices  Student health services  Teaching institutions  Research facilities  Military facilities  Veterans Administration facilities  Federal and State correctional institutions  Nursing homes  House calls/Home care PAs may work in any medical setting in which their supervising physician(s) practice, including private offices, general acute care hospitals, acute psychiatric hospitals, special
  8. 8. Acceptance and Quality of Care Patient Acceptance: Patient acceptance of PAs is excellent. Surveys repeatedly indicate patients are highly satisfied with the job competence and professional manner of PAs. The utilization of physician assistants has resulted in improved access to health care and enhanced patient satisfaction. Quality of Care: Results of studies comparing the primary care services of physician assistants with those of general or family physicians and general internists have consistently shown no discernible difference in the quality of their diagnostic or therapeutic care. Most findings indicate that PAs spend more time per patient visit, provide more thorough medical record documentation, and devote more time to patient education. Physician assistants contribute positively and significantly to health care delivery, particularly in rural and underserved areas. Depending on the setting, PAs may provide 65-90% of the procedures routinely performed by physicians in general or family practice, with a comparable level of skill to that of physicians.
  9. 9. Economic Factors Cost Effectiveness: Physician assistants have proven to be an asset in reducing malpractice exposure in PAs have been found to be highly cost private practice settings. This is attributed effective when fully utilized. Research has to the extra time PAs devote to patient shown that patient visit costs are less education and counseling, improved when PAs are employed in physicians’ patient compliance, and the close practices. At the same time, practice teamwork between the physician and PA. productivity measured in patient visits increased and practice income rises accordingly. Most physicians who hire PAs Reimbursement: do so less for the added profit than for Physician assistants usually don’t charge the added freedom, time, and flexibility directly for their services. Reimbursement employing a PA affords them. is made commonly through the supervising physician or the employing Salaries: institution. There is no fixed salary scale for physician Medicare currently reimburses for assistants. Salaries today vary widely and physician services provided by PAs, reflect the type of practice, the practice including surgical assists, under Parts location, the experience of the PA, and A and B at 85% of the physician fee the benefit of the PA to the practice. The schedule. In certain outpatient situations, American Academy of Physician Assistants it may be at 100%. (AAPA) maintain information on practice profiles, salaries and benefits which are In California, the Medi-Cal program updated annually. reimburses for services provided by PAs at 100% of the supervising physician’s Professional benefits such as continuing reimbursement rate. Medi-Cal has some medical education time and alternative specific requirements for physicians payment arrangements such as profit utilizing PAs. sharing can all be negotiated on an individual basis and formalized by written The private insurer reimburses at varying or verbal agreement. rates up to 100% of that of the physician. Professional Liability Insurance: Liability insurance covering the PA is generally paid by the employing physician and can be arranged in one of two ways. In the first, the PA is covered by the umbrella policy or “rider” of the physician. Many carriers do not increase the premium when a PA is employed; some increase it only slightly, while others may increase it significantly. Physicians should consult their carrier about their particular policy. In the second method, the PA may take out a separate individual policy .
  10. 10. A Scenario P erhaps the best way to understand what a PA does is to visualize one in practice. Here is a possible scenario involving one two of his own patients; a new mother who desires to learn the various methods of contraception, and an obese man wanting physician who has fully incorporated a to start a diet and exercise program. PA into his practice. They have worked together for two years. Dr. Q will attend a local continuing education seminar the next day; they have Dr. Q, a physician in private general practice, scheduled patients for Mr. J for that time. arrives at his office at 8:00 a.m. His PA, In the past Dr. Q was forced to close the Mr. J has just walked in. They look at their office on such occasions. He will carry a patient schedules for the day and discuss beeper so that the PA can contact him any potential problems. Mr. J inquires about immediately should any problems arise. changing the insulin regimen of a diabetic Tonight Mr. J will be on call, as he is two patient he has been following, and together nights every week. At week’s end, Dr. Q they work out a better dose schedule. will review the PA’s charts and countersign them. This process has become easy as his At 9:00 a.m., they start seeing patients in assistant’s knowledge and experience have separate exam rooms, with the nursing grown. Dr. Q feels pleasure in having taught staff assisting both. The PA handles the PA much during their work together, uncomplicated new cases, does physical and realizes that both of them stay mentally exams required for school or employment, sharp as a result. and sees patients with chronic problems returning for maintenance care. He orders For these services, Dr. Q pays his PA a and evaluates appropriate lab work, x-rays, competitive salary plus a percentage of the EKGs and writes drug orders working office income. At first, during an adjustment within protocols and formularies developed period, that salary was lower and there together with his supervising physician. was no percentage while the two learned to work together as a team. But as Dr. Q At 11:30 a.m., Mr. J consults with Dr. Q saw his office income and productivity rise, about a patient he has just seen who he increased the compensation accordingly. appears to be in heart failure. They review Still, it is much less than a physician-partner the case and decide to admit the patient would require, as his practice would not to the hospital. Mr. J makes the admission accommodate a full partner. His malpractice arrangements, and since he had planned premium is only slightly higher than it to make hospital rounds for Dr. Q this was before he employed the PA. Both Dr. afternoon, accompanies the patient to the Q and Mr. J are well satisfied with their hospital. While there, he reviews the charts relationship. of Dr. Q’s post-op patients, makes progress notes and written orders under conditions At first, patients had questions about the agreed on by Dr. Q, the hospital and the PA. PA, but after a short time they accepted him without question and many now Later he visits some of Dr. Q’s nursing specifically request to be seen by him home patients, and returns to the office at when making their appointments. And, the end of the afternoon to discuss patients many patients comment to Dr. Q that they who he feels should see the physician at appreciate the extra time the PA takes to their next visit. He also asks for advice explain his instructions and answer their about two in-patient problem cases. Dr. Q questions. Some were frankly amazed when asks the PA to spend some extra time with the PA made a house call. 10
  11. 11. For More Information About PAs 1. Up-to-date information on California Charles R. Drew University PAs, and employment information: Physician Associate Program 1731 E. 120th St. California Academy of Physician Assistants Los Angeles, CA 90059 3100 W. Warner Ave., Suite 3 (323) 563-5950 Santa Ana, CA 92704-5331 (714) 427-0321 FAX: (714) 427-0324 Stanford University Physician Associate Program 1215 Welch Rd., Module G . National information on programs, Palo Alto, CA 94305 legislation, and certification/ (650) 725-6959 recertification: American Academy of Physician Assistants, or UC Davis Medical Center Association of Physician Assistant Programs Physician Assistant Program 950 N. Washington St. 2516 Stockton Blvd., Suite 254 Alexandria,VA 22314 Sacramento, CA 95817 (703) 836-2272 FAX: (703) 684-1924 (916) 734-3551 National Commission on Certification of Western University Physician Assistants Physician Assistant Program 12000 Findley Rd., Suite 200 309 E. Second St. Duluth, GA 30097 Pomona, CA 91766 (678) 417-8100 FAX: (678) 417-8135 (909) 623-6116 Samuel Merritt College Physician Assistant Program . California regulations, applications 450 30th St. for licensure, and information for MD Oakland, CA 94609 supervising physicians and PAs: (510) 869-6623 Physician Assistant Committee Medical Board of California RCRMC/RCC Primary Care 1424 Howe Ave., Suite 35 Physician Assistant Program Sacramento, CA 95825-3237 16130 Lasselle St. (916) 561-8780 (800) 555-8038 (CA Only) Moreno Valley, CA 92551 (909) 571-6166 . Doctors of Osteopathic Medicine who Loma Linda University wish to supervise PAs should contact: School of Allied Health Professions Physician Assistant Program Osteopathic Medical Board of California Nichol Hall, Room 2033 2720 Gateway Oaks Dr., Suite 350 Loma Linda, CA 92350 Sacramento, CA 95833 (909) 558-4599 (916) 263-3100 Touro University - California Physician Assistant Program . California PA training programs, 1310 Johnson Ln. preceptorships, and general Vallejo, CA 94592 information: (888) 652-7580 USC School of Medicine Physician Assistant Program San Joaquin Valley College 1000 S. Fremont Ave. Primary Care Physician Assistant Program Unit 7, Bldg A-6, 4th Fl, Rm 6429 8400 W. Mineral King Ave. Alhambra, CA 91803 Visalia, CA 93291 (626) 457-4240 (559) 651-2500 x351 11
  12. 12. Copyright© 1979, The California Academy of Physician Assistants 3100 W. Warner Ave., Suite 3  Santa Ana, California 92704-5331 1TH EDITION 00