Physician Assistants in Geriatric Medicine
Pages 22 - 28
Physician assistants (PAs) are healthcare professionals who practice medicine with physician supervision. Their use is widespread in all areas of medical care delivery, including geriatrics. Over the past four decades, the role of PAs in American medicine has expanded and, as of 2003, PAs account for at least 10% of all outpatient contact.1 Of the nearly 65,000 PAs currently in practice in the United States, the majority work in ambulatory care settings, but with significant numbers in specialty and subspecialty areas. Their contribution to medical care delivery has become an important factor in serving an expanding and aging population.
Physician assistants make a contribution to medical care services to geriatric populations.2 The nature of PA practice is interprofessional, working closely and primarily with the physician, but also with the team of all healthcare professionals involved in the care of the patient.3 The American Geriatrics Society (AGS) includes the PA as a potential member of the interdisciplinary team delivering comprehensive rehabilitative services to the geriatric patient.4 To be most effective, interprofessional team members need to be cognizant of others’ roles and capabilities. The role of the PA can vary across specialties, geographical location, and facilities, but understanding the focus of PA training, legal basis of practice, and reviewing typical practice roles can serve as a foundation for greater role awareness. The purpose of this article is to present a brief update on the role of the PA and, in particular, to examine current status and potential of the PA in geriatric medicine.
Physician assistant education is founded on a medical model and typically is focused on a generalist, primary care foundation. Physician assistants are thus prepared to enter a wide variety of clinical career pathways. Physician assistant programs have placed an increased emphasis on geriatric medicine in their curricula, and recent accreditation requirements have mandated that all students must have supervised clinical practice experience in long-term care (LTC) and exposure to a geriatric population. Accredited PA programs must provide students with instruction and clinical experience in geriatrics, and there is a need identified by PA educators and geriatricians alike to augment the typical geriatric medicine curriculum.5,6 The core of the PA role is that they are trained to recognize their limitations and know the appropriate time to consult with the physician, as well as to grow as clinicians through self-directed continuing medical education.
The Physician Assistant: A Definition
The American Academy of Physician Assistants (AAPA) is the national organization representing PAs. The definition of the PA role in the AAPA Policy Manual reads:
Physician assistants are health professionals licensed or, in the case of those employed by the federal government, credentialed, to practice medicine with physician supervision. Physician assistants are qualified by graduation from an accredited physician assistant educational program and/or certification by the National Commission on Certification of Physician Assistants.
Within the physician-PA relationship, physician assistants exercise autonomy in medical decision making and provide a broad range of diagnostic and therapeutic services. The clinical role of physician assistants includes primary and specialty care in medical and surgical practice settings in rural and urban areas. Physician assistant practice is centered on patient care and may include educational, research, and administrative activities.7Legal Status
Physician assistants are licensed (or hold the equivalent of licensure) in all 50 states, the District of Columbia, and Guam, and are credentialed in the federal service, including the Air Force, Navy, Army, Public Health Service, and Department of Veterans Affairs.8 They are authorized to prescribe medications in all 50 states, the District of Columbia, and Guam. Qualifications to practice as a PA require that individuals be graduates of an educational program accredited by the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA), and pass the Physician Assistant National Certifying Exam (PANCE). The PANCE is a nationally standardized examination in medicine administered by the National Commission on Certification of Physician Assistants (NCCPA), with the content and standards developed in cooperation with the National Board of Medical Examiners (NBME). Initial successful completion of the PANCE is a required qualification for PA practice in almost all states. Over 92% of PAs in active practice hold current certification. To maintain certification, the NCCPA requires PAs to obtain 100 hours of continuing medical education every two years and to recertify by formal examination every six years.
Physician assistant regulations vary from state to state, particularly with regard to prescribing and supervision. State laws require that PAs be appropriately supervised by physicians, although this may or may not require the physical presence of the physician. Most state laws define supervision as physician oversight that can be met through availability of the physician for consultation via telephone or other means of communication and a policy of regular physician review of the PA’s work and documentation of patient encounters.
The AAPA defines physician-PA relationship as one that allows for “autonomy in medical decision making…” and requires that PAs apply a knowledge base and set of clinical skills to specific clinical situations. Physician assistant duties typically include the following tasks: eliciting a medical history; performing an appropriate physical examination; selecting and interpreting appropriate diagnostic tests; and synthesizing pertinent data to guide patient care decisions. These decisions may result in therapeutic interventions that are initiated prior to physician review of the specific intervention.
The “broad range of diagnostic and therapeutic services” described typically includes the ability to write prescriptions and often encompasses such clinical procedures as endoscopy, catheterization, casting, suturing, or bone marrow aspiration. Diagnostic and therapeutic procedures performed by PAs include (but are not limited to): venipuncture; intravenous catheter insertion; obtaining pharyngeal, blood, urine, or wound cultures; administering injections; obtaining electrocardiograms; inserting nasogastric tubes; and dressing wounds. Physician assistants are typically credentialed by employing institutions. Tasks that may be delegated by the supervising physician may include advanced procedures such as lumbar puncture, central venous catheterization, and endotracheal intubation.
Malpractice has been a subject that arises when discussing employment liability. To date, the liability of PAs in the United States is considerably less than physicians in comparable roles, as measured by medical insurance premiums and malpractice cases. The National Practitioner Data Bank records all medical malpractice cases that come to trial in the United States. This 15-year registry documents that the rate of settled litigation for PAs is less than one-fourth that of physicians in comparable roles.9Physician Assistant Education
The first PA program was developed at Duke University in the early 1960s, so the PA is a relatively new member of the healthcare team. There are now 136 accredited PA programs enrolling 9100 students across the United States.10 The average class size is 40.2, with a range between 11 and 176 students and an annual graduate output of 4700, representing more than 25% of the 17,000 doctors trained annually in the United States. More than 100 PA programs award a master’s degree or provide a graduate degree option, with almost all committed to this degree endpoint by 2008. This growth in PA graduates comes at a time when patient demand for access is increasing and medical school graduation rates have not kept pace with population growth.
It is becoming more likely that physicians, nurses, and other healthcare professionals will increasingly encounter a PA, as there are currently nearly 65,000 PAs in clinical practice as of 200711; the number of PA jobs is projected to increase by over 27% by 2014.12 The success of the model is also evidenced by other countries besides the United States expressing interest in enabling a similar class of healthcare provider. The AAPA is monitoring international PA development.
The majority of PA educational programs are focused on training primary care generalists, but graduates can branch out into almost any specialty. The ARC-PA defines the standards for the education of a PA, which include basic medical sciences, clinical preparatory sciences, behavioral and social sciences, information literacy, health policy and professional practice, and supervised clinical practice.13 The typical PA program curriculum averages 26.4 months, and since the majority of programs now are at the master’s degree level, the typical applicant already possesses a baccalaureate degree with a significant amount of science prerequisite coursework.10 The curriculum is typically divided into didactic instruction and supervised clinical experiences.
The ARC-PA standards specifically mandate supervised clinical practice experience in geriatrics. Additional instruction in the physical examination of geriatric patients, normal psychological development of geriatric patients, and end-of-life issues are also mandated.
The traditional PA role is centered on patient care and also encompasses patient counseling on preventive health and a commitment to life-long learning. Among practicing PAs, a majority (62.2%) are women. Physician assistants are versatile practitioners, as the PA credential permits them to hold multiple primary care or specialty positions over the course of a career. Physician assistant practice is not necessarily limited to one primary care or specialty area, and tends to be based on the specialty of the supervising physician. Tasks delegated to a PA must typically fall within the scope of practice of the supervising physician and comply with state regulations addressing the physician-PA relationship.
Although PA training is typically primary care focused, more than half of all PAs practice in surgical or medical subspecialty areas.14 There are some post-graduate PA residency training programs providing structured educational experiences in specialty areas, but the profession has resisted any certification requirement to practice in specialty areas as being a limitation on professional mobility. Most PAs do not complete postgraduate residency training programs.
Physician assistants can be found in every type of healthcare environment, including hospitals, private physician practices, multispecialty group practices, clinics, nursing homes (NHs) and other LTC facilities, correctional facilities, and mobile facilities. Early on in the profession’s history, it was recognized that PAs could fill gaps in access to healthcare experienced by rural or inner city populations. Most PAs are still actively practicing clinically, but many integrate their clinical knowledge with advanced degrees and move into administrative, educational, legal, clinical research, or other employment settings. Physician assistants can advance within clinical careers to greater responsibilities, but clinical practice always remains dependent upon the physician-PA relationship.3
With these general parameters of the PA role, specific delineation of tasks performed can be determined according to state law, institutional policy, and the physician-PA relationship.
Scope of Practice
Suggested Guidelines for Physician-Physician Assistant Practice were developed by the AAPA and American Medical Association (AMA).7 These guidelines were adopted by the AMA House of Delegates in 1995 and reflect the role of the PA as an agent of the supervising physician. The guidelines address issues related to establishing physician availability for consultation, the constraints imposed by state law regulating medical practice, proper representation of the respective practitioners to patients, periodic review of delegated tasks, and consideration of the level of training and experience of the PA. An additional parameter that must be considered is the facility policy regarding utilization of a PA.
As previously mentioned, the typical delegated tasks are related to evaluating patient problems, performing diagnostic or therapeutic procedures (including prescribing medications), and patient counseling. Physician assistants may elicit medical histories, perform physical examinations, order and interpret diagnostic studies, formulate and implement treatment plans, refer to specialists, and provide patient education. Physician assistants are expected to initiate life-saving measures when faced with emergency situations and are trained to manage acutely ill patients.
Prescriptive authority is an important component of PA practice, and PAs are authorized to write prescriptions in all 50 states. The level of authority does vary, ranging from authorization to prescribe controlled substances to being limited by a selection or formulary of drugs to choose from. Prescriptions written for hospitalized patients are usually considered “orders” and may fall under a different set of regulations. As an example, PAs in New York are authorized to write prescriptions for medications and certain categories of controlled substances. Physician assistant training program curricula necessarily includes a substantial pharmacology component.
The deployment of PAs in medical care is wide-ranging. Approximately half of PAs work in primary care and the others in medical and surgical specialty practices. Almost one-quarter are located in rural and frontier counties, usually in communities of fewer than 10,000, and 10% are in towns of less than 5000 population. Another 12% work in inner cities. The general medical education of PAs allows them the ability to move between various clinical settings and specialties: primary care, trauma units, and hospitals. In all settings, they share in diagnosing and treating common medical problems and providing wellness checks. Outside primary care, the PAs appear to be effective in all of the surgical specialties and the majority of the medical specialties.
Studies of PA employment and task analysis consistently reveal cost-effectiveness advantages. Demand for PA services has exceeded supply for the past ten years, with opportunities for employment fairly strong in nearly all parts of the country. The U.S. government, including the military and the Department of Veterans Affairs, employs over 12% of PAs; state governments and large health maintenance organizations are other major employers.
From the beginning, the satisfaction of patients with PAs has been consistently high, rivaling those of doctors. Acceptance by nurses, pharmacists, and other allied health occupations was slower than by doctors but eventually came about. Physician assistants are now regarded as safe and effective; the scrutiny they have undergone has been as extensive as any other innovation in healthcare delivery.
Career satisfaction has also been a concern of those interested in the profession; however, more than 20 studies show that PAs are generally satisfied with their role and are not interested in becoming a doctor. If asked, over 95% of PAs say they would become a PA again. This survey result is substantiated with an attrition rate of PAs estimated to be 2% per annum. Role frustration has not been a matter of concern to most.15
Physician Assistants in Geriatric Medicine
According to the 2006 AAPA Census, there were approximately 128 PAs who identified their primary specialty as geriatrics. Of those PAs identified as working in geriatrics, 63% were employed in a NH or LTC setting. Physician assistants performing a “geriatric assessment” elicit a significant amount of information regarding living situations, activities of daily living, and psychosocial and other functional status information that can be helpful to rehabilitation professionals. The PA can provide the therapy team (physical therapist, occupational therapist, physiatrist, rehabilitation nurse, psychologist) with an overview of the patient’s chronic and acute medical problems, level of disability, level of cognitive impairment, drug treatment, and other factors that may impact formulation or progress of a rehabilitation program.
While geriatric medicine is identified by only a small percentage of PAs as their primary specialty area, a significant number—1181 or 5.6% of all clinically active PAs—report that they work either in a NH or other LTC facility.14 A large number of PAs report treating elderly patients, arbitrarily defined as those 65 years of age or older. In the 2006 AAPA Census survey, PAs reported treating many patients for disorders seen primarily in the elderly population. For example, the AAPA reported that PAs reported performing approximately 3,565,471 visits for Alzheimer’s disease, 6,555,150 visits for osteoporosis, and 4,630,804 visits for overactive bladder/urge incontinence.16 A distinction can be made between PAs caring for people over age 65 years and those PAs providing comprehensive geriatric care. A geriatric care model has a holistic perspective, focusing on function, cognition, and special needs of patients typically 75 years of age or older.
The demographic shift toward an aging population has created a great need for PAs competent in caring for the elderly. In a study analyzing data from the 1997 National Ambulatory Medical Care Survey, of outpatient visits, 32% of all patients seen by a PA were age 65 years or older.17 Freddi Segal-Gidan, a PA in geriatric practice, noted the following:
PAs can act as key facilitators in caring for geriatric patients with multiple chronic, complex, interrelated problems and also in identifying acute problems that may arise. The physician-PA team at my facility coordinates an interdisciplinary approach to geriatric care and rehabilitation, ensuring that patients are medically stable for rehabilitation services and communicating information to therapists and other team members regarding a patient’s medical status.2
Although recognized for years, preparing a healthcare workforce for the “aging” of the population in the United States has not been well planned, and the elderly represent a large group of Americans with unmet healthcare needs.18 Recruiting and training PAs to provide services to geriatric populations is recognized as an avenue to address the currently unmet healthcare needs of the elderly population.19 The inclusion of greater geriatric medicine content in PA program curricula can have a PA workforce better prepared to provide needed services in a relatively short time. Curry et al20 reported on an increased focus on geriatrics in PA training curricula, and reviewed evidence that PAs can provide quality care and improve patient outcomes in ambulatory and institutionalized geriatric patients. PAs were recognized as effective providers of quality care in the geriatric care facilities as early as 1979.21
Therapy practitioners working in geriatrics may encounter a PA acting in the following roles: a primary medical caregiver utilizing (or not utilizing) a geriatric care model; a specialty care provider working with an orthopedist, neurologist, or physiatrist; an administrator; a clinical researcher; or as a direct member of a rehabilitation team in a multidisciplinary approach. Physician assistants are well positioned to function on interdisciplinary teams because they are trained to provide care in a team model.22 The AGS position paper on geriatric rehabilitation supports an interdisciplinary approach, and specifically includes the PA as a provider along with the MD and nurse practitioner (NP):
Rehabilitative or restorative care for older persons with complex needs is therefore optimally provided by an interdisciplinary approach, which may involve physical, speech, occupational and recreational therapists, physicians, nurses, social workers, and/or other health professionals. For specific needs, patients may be well served by the provider (MD, NP, PA) and one or more therapists.4
In addition to the typical PA tasks and responsibilities, the specific role of a geriatric PA presents many unique clinical challenges. As the AAPA states, “The health care of elders in the United States presents the clinician with social, medical, spiritual and political challenges that cut across the full spectrum of race, religion and social standing.”16 Multisystem medical problems become even more challenging in the context of ethical and social dilemmas of providing compassionate care. Physician assistants need to know when to refer patients for physical or occupational therapy services, and what information to give to help therapists effectively provide rehabilitative services. Geriatric patients require a substantial amount of coordination of care. Contact with families, lengthy discussions surrounding end-of-life care, and the coordination of care between many specialists is both time-consuming and critical in appropriate medical management of geriatric patients. Physicians often lack the time required to perform these vital functions. Physician assistants could be very effective at this coordination and liaison role, especially in a solo or small group medical practice.
Physician assistants can also have an important preventive role in the care of NH patients. Most NHs and LTC facilities do not have a full-time medical staff. Physicians will often visit the facilities on a weekly basis. Patients with acute problems are generally treated over the phone or sent to an emergency department. Having a full-time PA on staff at the LTC or NH facility can translate into patients being evaluated sooner and can prevent transfer to the hospital in many cases. One study found that employment of PAs and NPs in NHs was associated with a lower hospitalization rate for ambulatory care–sensitive diagnoses.23
Caring for elderly persons usually requires greater clinician time than other patient populations, and past reimbursement constraints and low levels of reimbursement for PA services set by the Centers for Medicare & Medicaid Services (CMS) may have deterred PAs from choosing to practice geriatric medicine. Recent gains in reimbursement and practice authority for PA services by CMS has helped improve the climate for PA geriatric practice. Physician assistants in geriatrics earn an average of $79,291 per annum, somewhat lower than the average annual income of all PAs of $84,396 per annum.14 Services provided by PAs are currently reimbursable through Medicare and Medicaid in all patient care settings, including home visits.2 Under recently expanded CMS guidelines, PAs may participate in telemedicine services and order durable medical equipment.24Conclusion
Physician assistants are well positioned to contribute to caring for our aging population, either as direct patient care providers or as members of multidisciplinary teams. Physician assistant training now includes mandatory geriatric medicine curricula, and the PA profession has an opportunity to help address the underserved geriatric segment of our population. Increased numbers of PAs, increased projected employment, increased practice authority, and increased reimbursement for PAs are all factors that are making it more likely that therapy practitioners will encounter a PA. The PA role is adaptable and evolving to meet societal healthcare needs. Physician assistants enjoy significant autonomy in medical decision-making, based on the physician-PA relationship, state law, and facility policy.
A PA can assume the role of a geriatric medicine provider who can offer comprehensive geriatric assessment with a focus on the functional status, cognitive status, and special needs of the patient. Geriatric patients often are clinically challenging, and may present with multiple interrelated, complex, chronic, or acute medical conditions requiring an interdisciplinary approach to care and rehabilitation. Physician assistants by training are capable of evaluating, referring, and monitoring patient services. Physician assistants have an interdependent role with members of the geriatric medicine team, and can provide therapists with valuable information regarding a patient’s functional, cognitive, and medical status. Their future is bright in geriatric care.
The authors report no relevant financial relationships.Mr. Brugna is Chair and Associate Professor, Department of Health Sciences, and Director, Physician Assistant Program, York College of the City University of New York, Jamaica, NY.
Mr. Cawley is Professor and Interim Director, PA Program, School of Medicine and Health Sciences; Professor, Department of Prevention and Community Health, School of Public Health and Health Services, The George Washington University, Washington, DC.
Dr. Baker is Dean, School of Science and Health, and Assistant Professor, Physician Assistant Program, Philadelphia University, Philadelphia, PA.References
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