Physician assistant

A physician assistant or associate (PA) is a healthcare professional who is licensed to practice medicine as part of a team with physicians.[1]

Physician assistants are concerned with preventing and treating human illness and injury by providing a broad range of health care services under the direction of a physician or surgeon.[2] Physician assistants conduct physical exams, diagnose and treat illnesses, order and interpret tests, prescribe medications, counsel on preventive health care and may assist in surgery.[3]

The occupational title originated in the United States in the 1960s; similar occupations outside the US include clinical officers in part of Africa and Feldshers in countries of the former Soviet Union.[citation needed]

Overview Physician assistants typically obtain medical histories, perform examinations and procedures, order treatments, diagnose diseases, prescribe medication, order and interpret diagnostic tests, refer patients to specialists as required, and first or second-assist in surgery. They work in hospitals, clinics and other types of health facilities, or in academic administration, and exercise autonomy in medical decision making. Physician assistants practice primary care or medical specialties according to a legal scope of practice that may vary across jurisdictions. A period of extensive clinical training precedes obtaining a license to practice as a physician assistant, and similar to physician training but shorter in duration, includes all systems of the human body. Renewal of licensure is necessary every few years, varying by jurisdiction. Physician assistants may also complete residency training, similar to physicians' residencies but significantly shorter, in fields such as OB/GYN, emergency medicine, critical care, orthopedics, neurology, surgery, and other medical disciplines.

History The PA profession was first proposed in the United States when Charles Hudson recommended to the American Medical Association (AMA) in 1961 the "creation of two new groups of assistants to doctors from nonmedical and nonnursing personnel."[4] Dr. Eugene A. Stead, Jr. of the Duke University Medical Center in North Carolina assembled the first class of physician assistants in 1965, composed of former U.S. Navy hospital corpsmen.[5] He based the curriculum of the PA program in part on his first-hand knowledge of the fast-track training of medical doctors during World War II.[citation needed] Two other physicians, Richard Smith at the University of Washington in Seattle, and Hu Myers at Alderson-Broaddus College in Philippi, West Virginia, also launched their own programs in the mid and late 1960s.

In the early 1970s, the U.S. Army produced eight classes of Physician Assistants, at 30 students per class, through the Academy of Health Sciences, Brooke Medical Center, Fort Sam Houston, Texas. (Academically accredited by Baylor University, Texas)[clarification needed][6]

Similar providers have different titles in other countries such as clinical officers in Africa, Clinical associates in South Africa, Assistant Medical Officers in Malaysia, Assistant Doctors in China, and Feldsher in countries of the former Soviet Union.[7]

Canada In Canada, PAs are represented by the Canadian Association of Physician Assistants. The first formally trained PAs graduated in 1984 from the Canadian Forces Medical Services School at Borden, Ontario.[8] The first civilian PA education programs were launched in 2008 at the University of Manitoba and McMaster University. A PA program is also offered at the Consortium of PA Education. PAs are currently practicing across Canada in the Canadian Armed Forces and are working in the public health care system in the provinces of Manitoba, Ontario, New Brunswick and Alberta. PAs are regulated in Manitoba and New Brunswick by the respective provincial college of physicians and surgeons. In both Ontario and Alberta the profession is not regulated, however, the Ontario Minister of Health has recommended that a mandatory registry be established which would be governed by the College of Physicians and Surgeons of Ontario. In Alberta a voluntary registry has been established for PAs under the College of Physicians and Surgeons of Alberta. PAs are permitted to practice by way of delegation under the provincial Medical Act. There are currently upwards of 400 PAs practicing in Canada.

United Kingdom Overview

The role of Physician Associate (PA) has been established in the United Kingdom since 2005. The role evolved from the position of Physician Assistant, developed in the USA in the 1960s. In 2012 the profession voted to change the name of Physician Assistant to Physician Associate, to distinguish themselves from another role within the NHS, with the same name.

Scope of Practice

PAs are trained under the medical model, similarly to doctors, to deliver high-quality medical care in both primary and secondary care settings. The role has developed to provide the medical service, similar to House Officers or Senior House Officers. They are trained to perform a variety of roles including diagnosis and taking medical histories.[9]

They work under the direct supervision of a doctor. Due to the infancy of the profession there is currently limited progression to senior posts, however there has been an emphasis on employers to develop dedicated study leave and training times to help develop their skills, this is often paired with junior doctor training. The current avenues which PAs can develop their skills are through research, teaching, training to become first assistants in surgery and running outpatient clinics and post-surgical follow ups. Tasks they perform include medical history taking, interpreting EKG and venipuncture/blood draws, among others.[10]

Regulation and regulatory body

The title of Physician Associate is not a protected medical profession, hence many PAs, who have been trained in pharmacology and IRMER [11] (ability to request radiology imaging- X-Rays) are NOT able to prescribe or request imaging. It has been noted that there may be loop holes to this, however UK-Association of Physician Associates [12] has re-affirmed their stance that this is against the law and the individual is liable to legal prosecution if found prescribing drugs or imaging. At present, there is no regulatory body for PAs, such as the General Medical Council (GMC) for doctors. The only current method of regulation within the professional body is membership to the Managed Voluntary Register (MVR)[13] for Physician Associates. This database, run by PAs for PAs, aims to identify all qualified PAs who are able to practice in the United Kingdom. It is designed to regulate the profession to maintain high standards and to prevent non-Physician Associate qualified individuals being employed in as a Physician Associate in the UK. Due to this problem it is mandatory to be a verified member of this register for employers to consider an application to a job posting.

Professional

Physician Associates in the United Kingdom are required to re-certify every 5–6 years and maintain up-to-date practice through attendance of training accumulating CPD hours (Continuous professional development), which need to be completed on an annual basis.

Training

PA training in the UK is through a 2-year Postgraduate Diploma in Physician Associate Studies. There are 3 universities currently offering the programme.

• St George’s University of London[14] • Aberdeen University [15] • Birmingham University (programme starts January 2014)[16]

Entry requirements

Both Aberdeen and St George’s require a science-based degree with a minimum 2:1 grade achieved. This includes biology, geology, psychology and biomedical based degrees. Applicants should preferably have experience in the health care industry, such as a HCA, auxiliary nursing. Applications from other professionals such as Nurses, radiographers and paramedics will also be considered.

Re-certification

All qualified PAs are required to re-certify every 5–6 years through a 2 hour MCQ exam, testing knowledge on all aspects of medicine, regardless of the individuals specialty.

United States Regulation In the United States, the profession is represented by the American Academy of Physician Assistants, and all PAs must graduate from a nationally accredited ARC-PA program as well as passing the national certification exam.[17] It was not until 1970 that the AMA passed a resolution to develop educational guidelines and certification procedures for PAs.[6] The Duke University Medical Center Archives has established the Physician Assistant History Center, dedicated to the study, preservation, and presentation of the history of the PA profession.[18]

Education and certification As of October 2013, there were 181 accredited PA programs in the United States.[19] Most educational programs are graduate programs leading to the award of master's degrees in either Physician Assistant Studies (MPAS), Health Science (MHS), or Medical Science (MMSc), and require a bachelor's degree and GRE or MCAT scores for entry.[19] Professional licensure is regulated by the medical boards of the individual states. Physician Assistant students train at medical schools and academic medical centers across the country.

Physician assistant education is based on medical education[20] although unlike medical school which lasts four years plus a specialty-specific residency, PA training is usually 2 to 3 years of full-time study, completed during their post-graduate studies, for a total of 6–7 years of rigorous science-based postsecondary education.[21] Medical school for physician assistants does not permit the student to work and is a serious commitment to the study of medicine. However, most PA students start their medical education with a background of health care experience. The didactic training of PA education consists of classroom and laboratory instruction in medical and behavioral sciences, such as anatomy, microbiology, pharmacology, pathophysiology, hematology, pathology, clinical medicine, and physical diagnosis, followed by clinical rotations in internal medicine, family medicine, surgery, pediatrics, obstetrics and gynecology, emergency medicine, and geriatric medicine, as well as elective rotations.[citation needed] Unlike physicians, who must complete a minimum of three years of residency after completion of medical school, PAs are not required to complete such residencies after they complete medical school. Despite this, there are residency programs in certain specialties for PAs who choose to continue formal education in such a format.[22] There are also PA to DO bridge programs for PAs who wish to practice as physicians allowing them to match for traditional medical residencies.

PA clinical postgraduate programs are clinical training programs which differ from training on the job in their inclusion of didactic education and supervised clinical experience to meet learning objectives which are clearly defined.[23] The Montefiore Medical Center Postgraduate Surgical Physician Assistant Program was established in 1971 as the first clinical postgraduate PA program to be recognized.[23] Currently, there are known to be 49 programs in various specialties such as Neurology, Trauma/Critical Care and Oncology.[24] The Association of Postgraduate Physician Assistant Programs was formed in 1988 as an instrument in the establishment of educational standards for postgraduate PA programs[23] and currently includes 50 member programs.[24]

A physician assistant may use the post-nominal initials "PA", "PA-C", "APA-C", "RPA" or "RPA-C", where the "-C" indicates "Certified" and the "R" indicates "Registered". The "R" designation is unique to a few states, mainly in the Northeast; The "A" indicates completion of the Army Flight Surgeon Course. Most PAs use "PA-C" During training, PA students are designated PA-S. The use of "PA-C" is limited only to those PAs currently certified and in compliance with the regulations of the national certifying organization, the National Commission on Certification of Physician Assistants (NCCPA).

In the United States, a graduate from an accredited PA program must pass the NCCPA-administered Physician Assistant National Certifying Exam (PANCE) before becoming a PA-C; this certification is required for licensure in all states.[25] In addition, a PA must earn and log 100 Continuing Medical Education (CME) hours and reregister his or her certificate with the NCCPA every two years. Every six years, a PA must also recertify by successfully completing the Physician Assistant National Recertifying Exam (PANRE)[26][27]

"National Physician Assistant Week" is celebrated annually in the US from October 6 through October 12. This week was chosen to commemorate the anniversary of the first graduating physician assistant class at Duke University on October 6, 1967.[28]

Scope of practice Physician assistants have their own medical licenses with distinct scope of practice.[29] Each of the 50 states has different laws regarding the prescription of medications by mid-level practitioners (which include PAs) and the licensing authority granted to each category within that particular State through the Drug Enforcement Administration (DEA).[30] PAs in Florida, Kentucky, Puerto Rico and the U.S. Virgin Islands are not allowed to prescribe any controlled substances.[31] Several other states place a limit on the type of controlled substance or the quantity that can be prescribed, dispensed, or administered by a PA.[31]

Depending upon the specific laws of any given state board of medicine, the PA must have a formal relationship on file with a collaborative physician supervisor. The physician collaborator must also be licensed in the state in which the PA is working, although he or she may physically be located elsewhere. Physician supervision can be in person, by telecommunication systems or by other reliable means (for example, availability for consultation).

Employment The first employer of PAs was the then Veterans Administration (VA), known today as the Department of Veterans Affairs. Today, the VA is the largest single employer of PAs, employing nearly 2000 PAs. One of the first three graduates of the Duke program in 1967 was Mr. Vic Germino who was employed after graduation by the Durham, NC VA Medical Center, where he remained for over 25 years. In July 2010, Mr. Germino was honored by the Veteran Affairs Physician Assistant Association (VAPAA) with an honorary membership and assigning him the special membership number 0001 in honor of Mr. Germino being the first PA employed by the VA.

According to the AAPA, there were an estimated 68,124 PAs in clinical practice as of January 2008.[citation needed]

In the 2008 AAPA census, 56 percent of responding PAs worked in physicians' offices or clinics and 24 percent were employed by hospitals.[32] The remainder were employed in public health clinics, nursing homes, schools, prisons, home health care agencies, and the United States Department of Veterans Affairs[33] Fifteen percent of responding PAs work in counties classified as non-metropolitan by Economic Research Service of the United States Department of Agriculture;[34] approximately 17% of the US population resides in these counties.[35]

The U.S. Department of Labor Bureau of Labor Statistics report on PAs states, "...Employment of physician assistants is expected to grow 27 percent from 2006 to 2016, much faster than the average for all occupations..."[36] This is due to several factors, including an expanding health care industry, an aging baby-boomer population, concerns for cost containment, and newly implemented restrictions to shorten physician resident work hours.

For PAs in primary care practice, malpractice insurance policies with $100,000–300,000 in coverage can cost less than $600 per year; premiums are higher for PAs in higher-risk specialties.[37]

Money magazine, in conjunction with Salary.com, listed the PA profession as the "fifth best job in America" in May 2006, based both on salary and job prospects, and on an anticipated 10-year job growth of 49.65%.[38] In 2010, CNN Money rated the Physician Assistant Career as the number two Best Job In America.[39] In 2012, Forbes rated the Physician Assistant Degree as the number one Master's Degree for jobs.[40] According to the 2012 National Salary Survey of PAs, the mean total income for physician assistants working full-time was $102,165.[41] Physician assistants in emergency medicine, dermatology, and surgical subspecialties may earn $100,000 to $200,000 per year.[42]

Federal Government, Uniformed Services, and U.S. Armed Forces PAs are employed by the United States Department of State as Foreign Service Health Practitioners (FSHP). PAs working in this capacity may be deployed anywhere in the world where there is a State Department facility. They provide primary care to authorized members of the state department. In order to be considered for the position of FSHP these PAs must be licensed and have at least two years of recent experience in primary care.[43]

U.S. Army PAs typically serve as Medical Specialist Corps officers within Army combat or combat support battalions located in the continental United States, Alaska, Hawaii and overseas.[44] These include infantry, armor, cavalry, airborne, artillery and (if the PA qualifies) Special Forces units. They serve as the "front line" of Army medicine and along with combat medics are responsible for the total health care of soldiers assigned to their unit, as well as of their family members.[citation needed]

PAs also serve in the Air Force and Navy as clinical practitioners and aviation medicine specialists, as well as in the Coast Guard and Public Health Service. The skills required for these PAs are similar to that of their civilian colleagues, but additional training is provided in advanced casualty care, medical management of chemical injuries, aviation medicine and military medicine.[citation needed] In addition, military PAs are also required to meet the officer commissioning requirements and maintain the professional and physical readiness standards of their respective services.[citation needed]

The Marine Physician Assistant (MPA) is a U.S. Merchant Mariner Staff Officer. A Certificate of Registry is granted through The United States Coast Guard National Maritime Center (NMC) located in Martinsburg, West Virginia.[45] Formal training programs for Marine Physician Assistants began in September, 1966 at the Public Service Health Hospital located in Staten Island, N.Y.[46]