Editors’ note: “Alliances” is a series written about the relationships that hospitalists have with members of the clinical care team—from the team members’ points of view. Each installment of “Alliances” provides valuable, revealing feedback that hospitalists can use to continually improve their intrateam relationships and, ultimately, patient care.
Several months ago, a patient with decompensated end-stage liver disease was admitted to the Internal Medicine Hospitalist Service at the University of Texas Medical Branch in Galveston and required a paracentesis. One of the new hospitalist faculty members was taken aback when the physician assistant (PA) on the service volunteered to do the procedure. “He was surprised,” says Karen Kislingbury, PA-C, a member of SHM’s Non-Physician Provider Task Force and a PA with the Internal Medicine Hospitalist Service, “that the scope of practice for the physician assistant included [performing] procedures.”
PAs are not new to the hospital setting, and their inclusion as physician extenders to increase patient access to care will likely increase in the current regulatory environment—especially state-mandated staff/patient ratios and resident work hour limitations. The efficacy of utilizing physician extenders to improve patient care and outcomes has been validated in studies over the past two decades. A recent Journal of Trauma study found statistically significant reductions in floor, ICU, and overall hospital lengths of stay after incorporating physician extenders into their trauma service.1
However, hospitalists unfamiliar with PAs may not understand their colleagues’ roles and scope of practice. As her anecdote illustrated, Kislingbury notes that “although PAs aren’t new to the healthcare delivery system, and physicians have been utilizing us for a long time, our partnership in the unique setting of hospital medicine is kind of new.”
Kislingbury’s colleague Ryan Genzink, PA-C, who works with Hospitalists of West Michigan, a private hospitalists-only group that subcontracts hospitalist services to Spectrum Health of Grand Rapids, Mich., agrees with her assessment.
“There are more and more PAs and [nurse practitioners] working in hospital medicine, and I think there is a lot of curiosity and some apprehension on the part of people who have not worked with these non-physician providers,” says Genzink.
Genzink, also a member of SHM’s Non-Physician Provider Task Force, speculates that the apprehension of physicians who have not worked with PAs may be due to a misunderstanding of the PA’s role. “They’re either underestimating or overestimating exactly what a PA can do or what they are getting when they hire a PA,” he says.
A Short History of the Profession
PA programs officially began in the mid-1960s at Duke University Medical School (Durham, N.C.). Eugene Stead, MD, is credited with developing the concept of the physician assistant as a health professional who would work with physician supervision to extend patient access to care, according to the American Academy of Physician Assistants.
For the first class of PAs in 1965, Dr. Stead selected Navy corpsmen who had received medical training and experience during their service in Vietnam. The curriculum was based on Dr. Stead’s knowledge of fast-track training of physicians during World War II. From this early program, the profession has evolved to more than 130 programs that now adhere to rigorous national accreditation standards set forth by the independent Accreditation Review Commission on Education for the Physician Assistant (ARC-PA). The ARC-PA is sponsored by the American Medical Association and the American College of Surgeons, among many other professional medical organizations (www.aapa.org/geninfo1.html).
Scope of Practice
Prerequisites to PA programs include two years of college courses in basic and behavioral science, as well as prior experience in healthcare. According to a report generated by the Association of Physician Assistant Programs, most PA students have earned a bachelor’s degree and have an average of 38 months of healthcare experience before being admitted to a PA program.2
The first year of PA education comprises a didactic curriculum with coursework in anatomy, physiology, biochemistry, pharmacology, physical diagnosis, pathophysiology, microbiology, clinical laboratory sciences, behavioral sciences, and medical ethics. In the second year, students receive hands-on clinical training through a series of rotations—typically in family and internal medicine, obstetrics and gynecology, pediatrics, general surgery, emergency medicine, and psychiatry. By the time they graduate (typical PA programs last an average of 26 months), PAs will have completed more than 2,000 hours of supervised clinical practice.
PAs work in all areas of medicine. Although hospital bylaws and state regulations often stipulate the PA’s scope of practice, the major determinant of duties is the supervising physician. The relationship between supervising physician and PA, says Kislingbury, is a collaborative one. Duties are “defined on an individual basis, and they are determined based on our [PAs’] experience, the physicians’ experience with us, and then the nuances of the system and the hospital itself.
“The PA who is hired should know what his or her scope of practice is,” she continues. “By the time they have graduated and obtained their license, they should know what their state allows them to do.”
For instance, according to the American Academy of Physician Assistants, 48 of the 50 states, plus the District of Columbia and [the U.S. Territory of] Guam, authorize PAs to prescribe medications. In California, PA prescriptions are referred to as “written prescription transmittal orders.”
“For the most part,” says Genzink, “the supervising physician determines what the PA is capable of doing, within the guidelines of state law.”
Within Genzink’s hospital medicine group (with which he has been affiliated for five years) the physician and PA roles are very similar.
“We see the same type of patients in a team approach. For instance, it’s not uncommon for one of us to order a test early in the day, and then, when results come back, the other person may be discharging that patient or prescribing other treatments, if necessary,” he explains. “In general, the physicians take care of the more complicated patients, while PAs take care of more routine patients.”
Genzink’s group experience aligns with findings of a 1998 University of Pittsburgh School of Nursing Study, which evaluated provider roles and patient outcomes in an acute care setting.3 Compared with acute care nurse practitioners and PAs, residents in that study tended to care for patients who were older and sicker.
Genzink reports that in his group initial histories and physicals, as well as the consultations, are performed exclusively by the PAs and then the physician takes over for treatment. “Based on the acuity of the patient,” says Genzink, “the physician may be right down there to see the patient immediately.”
Areas for Improvement?
Although the two PAs interviewed for this article report positive experiences working with hospitalists, they admit that some physicians continue to hold misperceptions about the PA’s role in caring for patients.
Kislingbury says that hospitalists could improve their delegation of duties to the PAs and recognize their scope of practice. She admits that delegation duties can be improved through gaining experience. “Although the PA profession has been around for a while, there are a surprising number of institutions that do not utilize physician assistants on the wards in routine rounds and bedside-type care,” says Kislingbury.
“I think some of the problems develop when they [physicians] hire a PA and expect to get a physician—and they [don’t],” says Genzink. “The easiest way for me to explain the role is to compare it to a teaching model. All physicians have been through residency programs. They understand the hierarchy that involves training and teaching residents. PAs come out of school ‘green,’ with the assumption that training will go on at the workplace. So, if a physician takes the same stance toward a new PA as they would toward an intern, that is a pretty close comparison.
“You begin by letting PAs or interns do a few simple things, and as they master those, you teach them more,” he continues. “And then, hopefully, over time they’ve been able to master everything that the physician is able to master. [Employing a PA] is a significant investment. And, it takes time. Sometimes, that process can be very easy, depending on the person. Sometimes it can be very slow, and I think that’s sometimes where some of the frustration may come in.”
Genzink adds that in his hospital medicine group, the physicians are familiar with the idea that part of their job as supervising physicians is to train new PAs.
Kislingbury points that out that PAs can also play a role in informing the physician team members about the range of cases they are allowed to treat, thus furthering the collaboration between PAs and hospitalists: “It is merely a matter of educating the team members about what we can and cannot do.”
Accordingly, the SHM Non-Physician Provider Task Force was formed to provide a resource to hospitalists who work with PAs and have questions about scope of practice, reimbursement, and other issues as they pertain to PAs and nurse practitioners. (Visit www.hospitalmedicine.org for more information.) The Task Force is a resource for non-physicians providers, too, offering educational opportunities at SHM meetings, more visibility with the specialty, and a voice for advocacy.
The Positives of the Collaboration
While the PAs report that hospitalists could improve in communicating about their practice roles with PAs, “There are so many things that hospitalists do right!” says Kislingbury. Calling the experience of working with hospitalists a privilege, she says that “where it is a true partnership, we are treated as equals, we are given the responsibility that our experience will allow, and we are truly team members.
“Hospitalists are geared into the efficiencies of the system and the nuances of the hospital. These are subtleties that come with practicing in an area for a long period of time, not just coming in for a month and then leaving and returning,” she says. “Hospitalists know the daily ins and outs, and it is really a pleasure to learn from them.”
Prior to his affiliation with Hospitalists of West Michigan, Genzink was employed directly by a hospital in Grand Rapids. The physicians with whom he now works have been hospitalists almost exclusively throughout their medical careers. “One of the main benefits they offer is availability, simply because we [the group’s practice members] are in the hospital 24/7,” he says. “They also have more experience in dealing with more complex issues, just as do the PAs that are working in our system.”
What about the notion that PAs and nurse practitioners are more skilled or practiced with patient and family communications? One study by Rudy, et al. found that nurse practitioners and PAs were more likely than residents to discuss patients with bedside nurses and to interact with patients’ families.3 Genzink does not find this to be the case in his group’s practice.
“That presumption [that PAs are more communicative with families and patients] may have come about simply because as the demands on hospitalists continue to grow and the workload increases, adding the PA to the team means there are more people to do things like that [handle family communications],” he says. “Certainly, in our group, the PAs do lots of patient education, and we talk to patients about end-of-life issues and other difficult matters as well. But that is not delegated to them; in our group, both the PAs and the physicians participate equally in patient and family communication.”
Hospitalists and PAs also complement each other in the interdisciplinary care team because, “as a general rule, hospitalists love to teach,” says Kislingbury. “They don’t forget that just because you have your PA degree your learning does not stop there. The PA profession is almost like on-the-job training. You are allowed to choose the specialty that you want, and you gain your experience when you enter that [arena], as opposed to an internship or residency, where you first gain experience and then enter the specialty. We so appreciate the ability of the hospitalist to teach because we are learning while doing, on a day-to-day basis. It’s invaluable to have their teaching.” TH
Gretchen Henkel also writes about dealing with difficult families in this issue.
- Christmas AB, Reynolds J, Hodges S, et al. Physician extenders impact trauma systems. J Trauma. 2005 May;58(5):917-920.
- Nineteenth Annual Report on Physician Assistant Educational Programs in the United States, 2002-2203. Alexandria, Va. Association of Physician Assistant Programs.
- Rudy EB, Davidson LJ, Daly B, et al. Care activities and outcomes of patients cared for by acute care nurse practitioners, physician assistants, and resident physicians: a comparison. Am J Crit Care. 1998 Jul;7(4):267-281.