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Physician Assistants in the United States


David E Mittman, physician assistant
Clinicians Group, 2 Brighton Road, Suite 300, Clifton, NJ 07012, USA
James F Cawley, professor, Physician assistant,
School of Public Health and Health Services, George Washington University, Washington, DC, USA
William H Fenn, professor, physician assistant,
College of Health and Human Services, Western Michigan University, Kalamazoo, MI, USA
Permission Granted to
Correspondence to: D E Mittman

The United States has since the 1960s developed a cadre of physician assistants to work in primary care. They mainly worksemi-autonomously in association with individual doctors, but an increasing number work in hospitals. They seem to be well accepted by both doctors and patients and can reasonably expect to take on any unfilled roles for which their training qualifies them

During the mid-1960s a new cadre of providers of medical care, physician assistants, was developed in the United States in an effort to relieve a nationwide shortage of doctors in primary care and to increase access to health care for people in under served areas. The first trainees were highly skilled military paramedics. Today, there are more than 44 000 physician assistants in America. Internationally, the physician assistant model has been in place since 1992 in the Canadian forces, and a somewhat comparable profession exists in India. In different countries, however---Germany, for example---a similar name may be used for a substantially different cadre.

The concept of a paramedical health care provider did not originate in the United States. In the 17th century, medical care was provided in Europe by "feldshers," and the Russian army adopted the model a century later. In the 1960s, China trained more than 1.3 million "barefoot doctors" to improve the delivery of health care. 12 Recently several countries have become interested in adapting the concept of physician assistants to their needs.  In the United Kingdom interest in the concept is increasing, as shown by the call by the NHS and the Royal College of Physicians for an early start of pilot projects. 34 We describe how physician assistants are trained and the role they play in American medicine.
Summary points

Physician assistants are interdependent semi-autonomous clinicians practicing in partnership with physicians, and are found in almost every medical and surgical specialty 

They perform similar tasks to their physician partners, including examination, diagnosis, diagnostic testing, treatment (including referral), and prescribing 

Research shows them to be capable of giving care comparable to that of physicians for similar services 

Physician assistants have improved access to health care for populations in rural, inner city, and other medically underserved areas 

With their training modified as needed to integrate with local health systems, physician assistants are a viable alternative to physicians in areas with shortages of doctors, such as the United Kingdom 

  Physician assistants' role

Physician assistants are clinicians who are licensed throughout the United States to practice medicine in association with physicians. They perform many of the tasks previously done solely by their physician partners, including examination, diagnosis, and carrying out investigations, as well as treatment and prescribing. All physician assistants must be associated with a physician and must practice in an interdependent role, described as "negotiated performance autonomy."5 They are not to be confused with "medical assistants," who in the United States are support workers. 

Physician assistants are not independent practitioners but practice-focused autonomous professionals delivering care in partnership with physicians, in a role described as "negotiated performance autonomy."5 This relationship allows them to staff satellite clinic offices, provide on-call services in the practice, and deliver care in rural areas, as in most states the physician partner need not be physically present for the physician assistant to practice. They may work as house staff in large academic teaching centers, replacing physicians whose posts are no longer funded, and they also serve as commissioned officers in all branches of the American armed forces. They have demonstrated social responsiveness by focusing on primary care practice, thus fulfilling the original intent of the profession's founders to improve access to health care for populations in rural, inner city, and other medically underserved areas. 

Numerous studies have shown that the quality of care given by physician assistants is at the level of that given by physicians in comparable situations, with high levels of patient satisfaction.6-11 Actuarial data do not show any increased liability as a result of using physician assistants.12 A growing body of research and extensive clinical experience shows that they are accepted by both patients and doctors and that their performance in terms of quality of care, expanded access, and cost effectiveness is satisfactory.13-20
  Training and certification

Physician assistants spend an average of 25 months studying an intensive core curriculum. This resembles a shortened form of traditional medical education, and emphasises a primary care, generalist approach. Most students have had four years of medical experience before they start their training.21 The United States has 130 training programmes in universities, medical schools, teaching hospitals, colleges, and the armed forces. In 2001, about 4500 physician assistants graduated.21 Competition for training is intense---in 2001 there were five applications for every place. 21 22 On graduation from accredited training physician assistants mustpass the national certifying examination of the National Commissionon Certification of Physician Assistants, an independent accrediting agency, after which they must complete 100 hours of continuing medical education every two years and pass a recertification examination every six years.
  Clinical duties

The licensing boards in 50 states and the District of Columbia recognize physician assistants as health care practitioners authorised to perform diagnostic and therapeutic tasks delegated to them by physicians. From a legal perspective, enabling legislation empowers physician assistants to perform any clinical task within the scope of practice of, and sanctioned by, their supervising physicians. This wide latitude acknowledges the broad basis of physician assistants' abilities and recognizes their physician partners as the best judges of individual physician assistants' knowledge and skills. 

This conceptual framework has led to physician assistants providing virtually every clinical service, excluding primary responsibility for major surgery. 14,16,18 This does not mean that every physician assistant is qualified to provide every service, even though they may be able to do so "legally." 

Physician assistants treat most primary care illnesses on their own without direct supervision by their physician partner. There are no "physician patients" as opposed to "physician assistant patients." Physician assistants routinely deal with uncomplicated sprains, strains, hypertension, bronchitis, depression, allergies, asthma, gynaecological problems, family planning, and trauma.
A typical case

A 65 year old man with chest pain is seen by a physician assistant who, after a thorough history and physical examination, orders and interprets appropriate tests, such as chest radiographs and an electrocardiogram. If necessary the patient is then either referred to the supervising physician or, in some practices, directly to hospital.

There is no definite point at which the physician must take over. Clinical responsibilities vary depending on physician assistants' experience, postgraduate training, and the confidence the physician partner, the clinic, or the institution have in them.

Physician assistants in community practice typically have a regular schedule of patients according to the needs of the particular practice---interviewing, examining, evaluating, diagnosing, and treating the vast majority of presenting patients---without the physician's presence in the room.16 This allows the physician to focus on the most difficult and complex cases, while still being available for consultation. 

In hospitals, physician assistants provide continuity of care for patients. This may take the form of attending private patients, or filling the role of house officer. The demand for physician assistant house officers continues to expand with the shrinking supply of physicians for such posts. They are authorized to prescribe in 47 states, in the District of Columbia, in Guam, and in all branches of the federal government (for example, the armed forces, the Department of Veterans Affairs). 
  Specialty practice

Most physician assistants (55% of graduates in the past 15 years 15 22 ) continue to practice in primary care, and studies have conservatively estimated that in such roles physician assistants can provide 80% or more of the services previously provided only by physicians---at the same level of quality. 21 23 They can be found in almost every medical and surgical specialty---both in broad specialties such as family medicine and general surgery and in subspecialties like cardiothoracic surgery, interventional neuroradiology, forensic medicine, occupational health, and dermatology. Specialised procedures performed by physician assistants tend to be specific to a particular clinical field or setting, not unlike those undertaken by physicians and commensurate with adequate formal or informal postgraduate training. Examples include insertion of central access lines and chest tubes, invasive diagnostic procedures, ambulatory surgery, harvesting of saphenous veins for bypass procedures, and many others. 

Physicians who work with physician assistants claim that the advantages outweigh the disadvantages. The physicians can work fewer hours, both in the office and on call, and as they are able to delegate many tasks they can provide better services. Physician assistants commonly share on-call time, and routinely run satellite clinics in underserved areas. 

Physician assistants allow the physician to have a colleague close at hand. The relationship creates a bond between the physician assistant and physician that is positive for both the practitioners and their patients. Sometimes physician assistants may be a slight encumbrance, requiring an inconvenient amount of the physicians' time, especially in the early stages of the partnership. Physicians are ultimately responsible for their assistants' work and must provide an adequate educational experience, conduct chart reviews, and ensure regular oversight of their clinical activities. 
  Comparison with nurse practitioners

On a daily basis, in the United States physician assistants and nurse practitioners function in similar roles. Both can diagnose, treat, and prescribe, but the training of physician assistants is generalist in nature and modeled on medical school curriculums. All physician assistants learn primary care and rotate through the major specialties while in training. Nurse practitioners, on the other hand, have traditionally been trained in one specialty (paediatrics, women's health, etc.). Recently, family practice as a specialty has gained in popularity. Physician assistants are employed more often as house officers within the hospital setting than are nurse practitioners; surgery and its subspecialties are the most popular in-house specialties. Physician assistants are also more involved in emergency care than are nurse practitioners. 

Politically, physician assistants consider themselves to be a part of medicine as a member of the physician-led team, and some physician assistants sit on physicians' state medical boards. In contrast, nurse practitioners come from a nursing background and feel closest to nursing. Most state legislation for nurse practitioners sets up the state board of nursing as their regulatory body. Although both groups seek to be part of the medical care team, most nurse practitioners do not feel a political need to be tied to a physician. This has led some nurse practitioners to seek independent practice, which physician assistants have not done. It is the setting and the specialty that determines how these two professions practice, rather than legislative or professional regulations. 
  The future

Although it is difficult to predict how physician assistants will further evolve and progress, they can reasonably expect to take on any unfilled roles for which their training qualifies them. Undoubtedly, demand for health care will continue to escalate as the population ages and new treatments and techniques are developed and the inexorable development of new forms of treatment and new techniques. Thus, the position of physician assistants in the United States seems secure and growing---the numbers of practising physician assistants are projected to reach 53,200 by 2005 and 79,000 by 2015. 14 15 The evolution of the profession, as it matures and barriers to practice continue to be removed, is likely to involve a degree of innovation not yet conceptualized. With their continuing commitment to competency based primary care, improved access to care, and dynamic lifelong learning, physician assistants are well positioned to remain integral to the 21st century US health care network. 

Contributors: DM conceived the idea for the paper and coordinated the writing and editing. All authors discussed the core ideas and contributed to the writing and editing. JC researched references and provided citations. WF researched references and provided guidance. DM is guarantor.
1. Hooker RS, Cawley JF. Physician assistants in US medicine. New York: Churchill Livingston, 1997
2. Ballweg R, Stolberg S, Sullivan EM, eds. Physician : a guide to clinical practice. 2nd ed. Philadelphia: WB Saunders, 1999:1-2
3. Stationery Office. The NHS plan: a plan for investment, a plan for reform. London: Stationery Office, 2000
4. Royal College of Physicians. Skill mix and the hospital doctor; new roles for the health care workforce. London: RCP, 2001. (Working party report.) (accessed 14 Aug 2002). 
5. Schneller ES. The physician: innovation in the medical division of labor. Lexington: Lexington Books, 1978:18
6. Hooker RS, Potts R, Ray W. Patient satisfaction: comparing physician assistants, nurse practitioners and physicians. Permanente Journal 1997; 1: 38-42
7. Counselman FL, Graffeo CA, Hill JT. Patient satisfaction with physician assistants (PAs) in an ED fast track. Am J Emerg Med 2000; 18: 661-665. 
8. Miller W, Riehl E, Napier M, Barber K, Dabideen H. Use of physician assistants as surgery/trauma house staff at an American College of Surgeons-verified level II trauma center. J Trauma 1998; 44: 372-376. 
9. Hooker RS, McCaig LF. Emergency department uses of physician assistants and nurse practitioners: a national survey. Am J Emerg Med 1996; 14: 245-249.
10. Ruby EB, Davidson LJ, Daly B, Clochesy JM, Sereika S, Baldisseri M, 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; 7: 267-281.
11. Oliver DR, Conboy JE, Donahue WH, Daniels MA, McKelvey PA. Patients' satisfaction with physician assistant services. Physician Assist 1986; 10(7): 51-54, 57-60. 
12. Cawley JF, Rohrs FC, Hooker RS. Physician assistants and malpractice risk: findings from the national practitioner data bank. Fed Bull 1999; 85: 242-246
13. Hooker RS, McCaig LF. Use of physician assistants and nurse practitioners in primary care, 1995-1999. Health Aff (Millwood) 2000; 20: 231-238
14. American Academy of Physician Assistants. Into the future: physician assistants look to the 21st century. Developed for the Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions. April 1999. (accessed 14 Aug 2002.)
15. Cooper RA, Laud P, Dietrich CL. Current and projected workforce of nonphysician clinicians. JAMA 1998; 280: 788-794.
16. Cooper RA, Henderson T, Dietrich CL. The roles of nonphysician clinicians as autonomous providers of patient care. JAMA 1998; 280: 795-802.
17. Cawley JF, Jones PE. Nonphysician clinicians in the health workforce. JAMA 1999; 281: 509-510
18. Cawley JF. Nonphysician supply and requirements in the health workforce: personnel and policy. N Y Health Sci J 1998; 2: 117-127
19. Jones PE, Cawley JF. Physician assistants and health system reform: clinical capabilities, practice activities, and potential roles. JAMA 1994; 271: 1266-1272.
20. Hooker RS. Cost-benefit analysis of physician assistants [thesis]. In: Portland: Portland State University, 1999
21. Simon AF, Link MS. Seventeenth annual report on physician assistant educational programs in the United States, 1999-2000. Alexandria: Association of Physician Assistant Programs, 2001
22. American Academy of Physician Assistants. 2000 general census. Alexandria: AAPA, 2000
23. Pew Health Professions Commission and the Center for the Health Professions. Charting a course for the 21st century: physician assistants and managed care. San Francisco: Centre for the Health Professions, University of California at San Francisco, 1998
  More Examples of What Physician Assistants / Associates Do..

Physician Assistant in Cardiovascular Surgery   Back to Top

A Cardiovascular Surgery team consists of specialists devoted to providing the highest quality medical and surgical care. An integral member of this team is the nationally certified Physician Assistant who provides all
aspects of surgical care under the direction of the surgeon.  A physician assistant's skills include, but are not limited to:
*performing pre-operative history and physical examination of the patient;
*Surgical removal of the vein that is used for bypass grafts during surgery; and
*providing care to the patient after surgery. 

Physician Assistants
by Wendy J. Meyeroff
Monster Contributing Writer

Working alongside physicians, Bill Mahaffy has harvested arteries and treated patients in cardiac-care units, but he's not a physician; he's a physician assistant (PA), an occupation that is expected to be one of the fastest-growing over the coming years. 

PAs, who work under the supervision of doctors, are highly trained, licensed healthcare professionals who treat and diagnose patients, perform various medical procedures and act as a liaison with nurses, lab techs and others on the healthcare team. In 48 states and the District of Columbia, PAs can even prescribe medication. 

With greater demand for healthcare services, Mahaffy says PAs are “taking care of about 80 percent of what the doctors used to,” freeing doctors to focus on more complicated cases. 

For those willing to undergo the rigorous required medical training, the PA profession offers excellent prospects and a variety of opportunities for specialization. 

Fast-Growing Field

Mahaffy, a certified physician assistant (PA-C) at Evangelical Community Hospital in Columbia, Pennsylvania, became a PA about 10 years ago after 25 years as a paramedic. “I had colleagues who were PAs, and it seemed like a logical progression,” he explains. “It was the best career choice I ever made.” 

It's a promising one as well. According to the US Bureau of Labor Statistics, the occupation will be the third fastest-growing professional job in the nation through 2012, when the number of PAs is expected to increase to 94,000, up 49 percent from 2002. The median annual salary is about $65,000, with the top 10 percent earning more than $90,000. 

While salaries are high, aspiring PAs must be willing to tackle one of the more extensive health education programs outside of traditional medical school. Most physician assistant programs [] require applicants to have previous healthcare experience and some college education. The typical applicant holds a bachelor's degree and has worked in healthcare for four years, according to the American Academy of Physician Assistants []. PA training usually takes about two years full-time. In addition, graduates must pass a national certifying exam to obtain their state licenses. Continuing education is also required. 

Like Mahaffy, many PAs segue naturally into the occupation from other healthcare fields. Mahaffy has seen former nurses, exercise physiologists, fitness trainers and even two mortuary technicians become PAs. 

The Adrenaline Rush

PAs can be generalists or specialize in areas such as cardiology, pediatrics, psychiatry or trauma. []

Mahaffy, who is president of the American Association of Surgical Physician Assistants, [] is a surgical PA specializing in cardiothoracic procedures. He's harvested arteries for cardiac surgeons, put in dialysis catheters and inserted feeding tubes. Today, as a hospitalist (another specialty), he works anywhere outside the OR where surgical expertise is needed. For example, one of his duties in the cardiac-care unit is providing chest drainage to patients with congestive heart failure. 

Mahaffy works five days on, five days off, starting at 5:30 a.m. or 6 a.m. for what are supposed to be 10 or 12-hour shifts, but he stays as long as he's needed. His specialty can be “a young man's game,” he admits. “You can live on adrenaline and caffeine.” 

In a Family Way

Charlene Morris, MPAS, PA-C, offers another look at a PA's life. A former lab tech, Morris has been a family-practice PA for 24 years. While she has been employed at major medical centers, she now works alongside a family-practice physician at the B.F. Taylor Medical Arts Family Medicine Clinic in the small town of Burkesville, Kentucky. 

She describes the relationship with the doctor she supports as “very complementary” and says she loves the versatility of family medicine. “I'll handle everything from colds and rashes, to sports injuries, to people with diabetes,” says Morris, who is president of the Association of Family Practice Physician Assistants. []

Earlier this year, she widened her work's scope by dividing her time between the clinic and the Cumberland County (Kentucky) ER. “I've had to go back and expand my suturing skills, and we have to be up on advanced cardiac life support,” she says. 

Morris and Mahaffy emphasize the flexibility in their careers and agree that they could move into other areas, from neonatal to aerospace medicine. “PAs can work in any and all settings with their physician colleagues,” Mahaffy says.