Physician assistants in occupational medicine: how do they compare to occupational physicians?

BACKGROUND: Physician assistants (PAs) have been present in occupational and environmental medicine (OEM) in the USA since 1971, yet remarkably little is known about their activity. METHODS: An administrative study of PA activities was undertaken and compared with the activities of physicians in the same occupational medicine setting. Patients were not triaged to either provider and all resources of care were recorded for the visit. An episode of care approach was used for the analysis. RESULTS: The characteristics of patients seen by each provider were similar in age, gender ratio and severity of injury. Physicians saw a mean of 2.9 patients/h and PAs 2.5, but PAs worked more hours and saw more patients per year than physicians. The average charge per patient visit and total charge for an episode of care were similar. Differences between PAs and physicians were seen in the areas of 'limited duty' duration given to patients and on average PAs prescribed 15 days and physicians 17 days. PAs referred a patient 19.7% of the time, while physicians referred 17.4%. Most of the referrals were to physical therapy. The salary of a physician, based on an hourly rate, was approximately twice as much as a PA. CONCLUSION: The use of PAs in OEM may represent a cost-effective advantage from an administrative standpoint. Clearly, more research is necessary in determining the role and utilization of PAs in OEM and how they may improve the delivery of physician services.     

National estimates of physician assistant productivity

Analysis of productivity data from a nationally representative sample of physician assistants (PAs) showed that PAs performed 61.4 outpatient visits per week compared with 74.2 visits performed by physicians, for an overall physician full-time equivalent (FTE) estimate of 0.83. However, productivity of PAs varies strongly across practice specialty and location, with generalist PAs performing more visits than their specialist counterparts. Rural PA productivity is higher than urban productivity because of the concentration of generalist PAs in rural settings. A generalist PA physician FTE estimate of 0.75 appears to be more accurate than the 0.5 currently under consideration in proposed modifications to Health Personnel Shortage Area designation regulations.     

Satisfaction and well-being of primary care providers in managed care

We compared perceptions about the practice environment and the job satisfaction of physician assistants (PAs), nurse practitioners (NPs), and primary care physicians in a large group-model HMO. The data source was a self-administered mail survey (average response rate = 79%). PA/NPs and primary care physicians reported that professional autonomy was not a problem and were satisfied with most aspects of practice in this setting. Common areas of dissatisfaction included patient load and amount of time with patients. PA/NPs were more likely than the physicians to experience stress on a daily basis, however, and were less likely to report that they would choose the practice setting again. They also were significantly less satisfied than the physicians with their incomes and fringe benefits. Our findings suggest that more attention should be given to practice conditions and compensation of PAs and NPs in managed care.     

Survey approach to estimating demand for physician assistants

A national probability sample of physicians was surveyed by mail to provide an estimate of the number of job openings for physician assistants (PAs). The responses were used to undertake an empirical analysis of the factors which influence a physician's decision to hire a PA. Estimates were adjusted to account for survey non-response. This approach may be useful for estimating the employment demand for other types of health workers employed by physicians.It was found that in 1976 there was an unconditional demand for 20.338 PAs and a further conditional demand for 3417 PAs. This contrasts sharply with the fact that as of March 1977 only 4845 PAs had graduated from training programs. Approximately 53% of this employment demand was from physicians in the primary care specialties (general/family practice, obstetrics/gynecology, internal medicine, and pediatrics). Of note was the finding that physicians expected to pay PAs a lower salary than was being received in the market place. Further, 27% of physicians not willing to hire PAs indicated lack of knowledge about them as the main reason for not hiring.     

Physician extenders increase healthcare access

To ensure rural residents access to primary care services, Saint Vincent Hospital and Health Center, Billings, MT, operates five physician-operated clinics, located between 8 and 81 miles from Billings. Two of the clinics are in communities that are not large enough to sustain a physician practice, so they are staffed by certified physician assistants (PA-Cs). Licensed and practicing with supervision of a physician, PAs provide a variety of patient care services in virtually every medical specialty and environment. One-third of the nation's PAs work in primary care health professional shortage areas, providing services comparable to those of a family practitioner. National studies reveal a high degree of satisfaction among both consumers and supervising physicians regarding the level of care provided by PAs. Professional liability claims against PAs are fewer than those against physicians, probably because of the higher degree of communication and attention patients receive as a result of the team approach. PAs can increase patient contact hours, decrease waiting times, and improve access to care overall. In addition, PA utilization is a cost-effective approach to healthcare delivery.     

Physician Assistants in Primary Care: Trends and Characteristics

PURPOSE

Physician assistants (PAs) have made major contributions to the primary care workforce. Since the mid-1990s, however, the percentage of PAs working in primary care has declined. The purpose of this study was to identify demographic characteristics associated with PAs who practice in primary care.

METHODS

We obtained data from the 2009 American Academy of Physician Assistants’ Annual Census Survey and used univariate analyses, logistic regression analyses, and χ² trend tests to assess differences in demographics (eg, age, sex, race) between primary care and non–primary care PAs. Survey respondents had graduated from PA school between 1965 and 2008.

RESULTS

Of 72,433 PAs surveyed, 19,608 participated (27% of all PAs eligible to practice). Incomplete questionnaires were eliminated resulting in a final sample of 18,048. One-third of PAs reported working in primary care. Female, Hispanic, and older PAs were more likely to work in primary care practice. Trend tests showed a decline in the percentage of PAs working in primary care in the sample overall (average 0.3% decrease per year; P <.0001). In the cohort of 2004-2008 graduates, however, the percentage of primary care PAs increased slightly by an average of 0.9% per year (P = .02). Nonetheless, the low response rate of the census limits the ability to generalize these findings to the total population of PAs.

CONCLUSIONS

Demographics associated with an increased likelihood of primary care practice among PAs appear to be similar to those of medical students who choose primary care. Knowledge of these characteristics may help efforts to increase the number of primary care PAs.Key Words: physician assistants, workforce, primary health care     

Use of physician assistants and nurse practitioners in primary care, 1995-1999.

Federal policies and state legislation encourage the use of physician assistants (PAs) and nurse practitioners (NPs) in primary care, although the nature of their work has not been fully analyzed. In this paper we analyze primary care physician office encounter data from the 1995-1999 National Ambulatory Medical Care Surveys. About one-quarter of primary care office-based physicians used PAs and/or NPs for an average of 11 percent of visits. The mean age of patients seen by physicians was greater than that for PAs or NPs. NPs provided counseling/education during a higher proportion of visits than did PAs or physicians. Overall, this study suggests that PAs and NPs are providing primary care in a way that is similar to physician care.     

The contribution of nurse practitioners and physician assistants to generalist care in Washington State

OBJECTIVE: To quantify the total contribution to generalist care made by nurse practitioners (NPs) and physician assistants (PAs) in Washington State. DATA SOURCES: State professional licensure renewal survey data from 1998-1999. STUDY DESIGN: Cross-sectional. Data on medical specialty, place of practice, and outpatient visits performed were used to estimate productivity of generalist physicians, NPs, and PAs. Provider head counts were adjusted for missing specialty and productivity data and converted into family physician full-time equivalents (FTEs) to facilitate estimation of total contribution to generalist care made by each provider type. PRINCIPAL FINDINGS: Nurse practitioners and physician assistants make up 23.4 percent of the generalist provider population and provide 21.0 percent of the generalist outpatient visits in Washington State. The NP/PA contribution to generalist care is higher in rural areas (24.7 percent of total visits compared to 20.1 percent in urban areas). The PAs and NPs provide 50.3 percent of generalist visits provided by women in rural areas, 36.5 percent in urban areas. When productivity data were converted into family physician FTEs, the productivity adjustments were large. A total of 4,189 generalist physicians produced only 2,760 family physician FTEs (1 FTE = 105 outpatient visits per week). The NP and PA productivity adjustments were also quite large. CONCLUSIONS: Accurate estimates of available generalist care must take into account the contributions of NPs and PAs. Additionally, simple head counts of licensed providers are likely to result in substantial overestimates of available care. Actual productivity data or empirically derived adjustment factors must be used for accurate estimation of provider shortages.     

The feminization of the physician assistant profession

Although the physician assistant profession has historically been male-dominated, women now comprise over sixty percent of physician assistants (PAs) in the U.S. This paper explores the reason for the increase of women into the physician assistant profession in recent decades and whether gender differences exist in how PAs are utilized. Twenty-one qualitative interviews with male and female physician assistants and key informants were conducted to assess the reasons for the influx of women. In addition, data from the American Academy of Physician Assistants Census Survey (n = 16, 569) were analyzed to assess current gender differences in employment characteristics of PAs. In the interviews, female PAs reported entering the profession because it allowed them to practice within the medical model without having the high expense and demanding schedule of medical school. In fact, they claimed that the profession was quite compatible with family life. Significant gender differences were found in work characteristics, primary employer type, and practice specialty. Although women tend to concentrate in practice areas of women and children's health, evidence suggests that they are moving beyond these traditional roles into areas such as internal medicine and surgery.     

Examining attitudes of specialist physicians regarding physician assistant referrals

Referral of a patient from a primary care provider to a referral specialist physician for consultation is an important link in the continuum of patient care. Although the relationship between the physician assistant (PA) and supervising physician has been studied extensively, the effectiveness of the relationship between the primary care PA and the referral specialist physician is unclear. The purpose of this study was to examine the attitudes of the referral specialist physician toward direct referral of patients from primary care PAs. A random sample of 5,000 specialist physicians in five specialty areas across the United States were surveyed to determine their willingness to accept referrals from PAs, their attitudes about the appropriateness of PA referrals, and reasons for dissatisfaction, if any. Data analysis revealed that specialist physicians generally are willing to accept patient referrals from primary care PAs and that specialist physicians generally are satisfied with the appropriateness and timeliness of referrals from PAs. Whether or not the specialist physician employed (supervised) a PA in his or her own practice made a significant difference in level of satisfaction with PA referral. To determine the significance of these results, more research is needed to determine specialist physician satisfaction with referrals from primary care physicians compared with PAs.     

Primary Health Care in Community Health Centers and Comparison with Office-Based Practice

We examine the roles of nurse practitioners (NPs), physician assistants (PAs), and nurse midwives (CNMs) in community health centers (CHCs). We also compare primary care physicians in CHCs with office-based physicians. Estimates are from the National Ambulatory Medical Care Survey, a nationally representative annual survey of nonfederal, office-based patient care physicians and their visits. Analysis of primary care delivery in CHCs and office-based practices are based on 1,434 providers and their visits (n = 32,300). During 2006–2007, on average, physicians comprised 70% of CHC clinicians, with NPs (20%), PAs (9%), and CNMs (1%) making up the remainder. PAs, NPs, and CNMs provided care in almost a third of CHC primary care visits; 87% of visits to these CHC providers were independent of physicians. Types of patients seen by clinicians suggest a division of labor in caring for CHC patients. NPs and PAs were more likely than physicians to report providing health education services. There were no other differences among services examined. Office-based physicians were less likely to work alongside PAs/NPs/CNMs than CHC physicians. CHC staffing is contingent on a variety of providers. CHC staffing patterns may serve as models of primary care staffing for office practices as demand for primary care services nationwide increases.     

Growth and change in the physician assistant workforce in the United States, 1967-2000

The physician assistant (PA) profession grew rapidly in the 1970s and 1990s. As acceptance of PAs in the health care system increased, roles for PAs in specialty care took shape and the scope of PA practice became more clearly defined. This report describes key elements of change in the demography and distribution of the PA population between 1967 and 2000, as well as the spread of PA training programs. Individual-level data from the American Academy of Physician Assistants, supplemented with county-level aggregate data from the Area Resource File, were used to describe the emergence of the PA profession between 1967 and 2000. Data on 49,641 PAs who had completed training by 2000 were analyzed. More than half (52.4%) of PAs active in 2000 were women. PA participation in the rural workforce remains high, with more than 18% of PAs practicing in rural settings, compared with about 20% in 1980. Primary care participation appears to have stabilized at about 47% among active PAs for whom specialty is known. By 2000, 51.5% of practicing PAs had been trained in the states where they worked. The profession has grown rapidly; 56% of all PAs were trained between 1991 and 2000. In 2000, more than 42% of accredited PA programs offered a master's degree, compared to master's degree programs in 1986. Although many critical issues of scope of practice and patient and physician acceptance of PAs have been resolved, the PA profession remains young and continues to evolve. Whether the historical contribution of PAs to primary care for rural and underserved populations can be sustained in the face of increasing specialization and higher-level academic credentialing is not clear.     

Evaluation of physician assistants in National Health Service Scotland

Physician assistants (PAs) have medical training and work supervised by a doctor. In 2006-2008 the Scottish Government piloted use of USA-trained PAs. The aim of the paper is to evaluate the impact and contribution made by PAs to delivering effective health care in National Health Service (NHS) Scotland. Mixed methods, longitudinally, including interviews, feedback forms and activity data collection. Data analysis used nVivo, SPSS and Excel. Participants were 15 USA-trained PAs, medical supervisors and team members, 20 patients, four NHS senior managers and three trade union representatives. Settings were four Scottish NHS Boards where PAs worked in primary care, out of hours clinics, emergency medicine, intermediate care and orthopaedics. Two minor patient safety issues arose. Patients were satisfied with PAs. Scope of practice did not replicate US working. Inability to prescribe was a hindrance. PAs tended to have longer consultations, but provided continuity and an educational resource. They were assessed to be mid-level practitioners approximating to nurse practitioner or generalist doctor. Valued features were generalism, medical background, confidence differential diagnosis and communication. Interviewees suggested PAs could fulfil roles currently filled by medical staff, potentially saving resources. In conclusion, there is potential for PAs to fulfil distinctive mid-level roles in the Scottish NHS adding value in continuity, communication and medical approach.     

Predictive modeling the physician assistant supply: 2010-2025

Objective

A component of health-care reform in 2010 identified physician assistants (PAs) as needed to help mitigate the expected doctor shortage. We modeled their number to predict rational estimates for workforce planners.

Methods

The number of PAs in active clinical practice in 2010 formed the baseline. We used graduation rates and program expansion to project annual growth; attrition estimates offset these amounts. A simulation model incorporated historical trends, current supply, and graduation amounts. Sensitivity analyses were conducted to systematically adjust parameters in the model to determine the effects of such changes.

Results

As of 2010, there were 74,476 PAs in the active workforce. The mean age was 42 years and 65% were female. There were 154 accredited educational programs; 99% had a graduating class and produced an average of 44 graduates annually (total n=6,776). With a 7% increase in graduate entry rate and a 5% annual attrition rate, the supply of clinically active PAs will grow to 93,099 in 2015, 111,004 in 2020, and 127,821 in 2025. This model holds clinically active PAs in primary care at 34%.

Conclusions

The number of clinically active PAs is projected to increase by almost 72% in 15 years. Attrition rates, especially retirement patterns, are not well understood for PAs, and variation could affect future supply. While the majority of PAs are in the medical specialties and subspecialties fields, new policy steps funding PA education and promoting primary care may add more PAs in primary care than the model predicts.Physician assistants (PAs) and nurse practitioners (NPs) are considered essential parts of the contemporary U.S. medical workforce.¹ As medical providers, PAs have been essential during times of physician shortages and, historically, it was a lack of doctors in underserved areas that first spurred their creation.² Once again, experts believe that the U.S. faces an insufficient cadre of physicians, with projections indicating that the supply will be unable to keep pace with demand; by 2025, a shortage of 124,000 primary care physicians is anticipated.^3,4 Consequently, analysts have suggested that there will be an increased reliance on PAs and NPs.^5,6Models developed to predict the supply of physicians under various scenarios are important for health planners. Because little research has included the supply of PAs and NPs in these projections, accurate numbers of clinically active providers are needed for rational medical workforce planning. Such key data could provide policy makers with needed information to augment physician services in both the specialty and primary care sectors of the medical workforce.     

Physician Assistants – A solution to wait times in Canada?

Access to medical care is limited in most of Canada, and the population often endures lengthy waiting times to see a physician. The use of new and varied health care providers has been suggested as a means to alleviate the shortage of physicians. This paper reviews the history and role of the Physician Assistant (PA), both in Canada and internationally, and outlines the clinical competencies currently held by this provider to fill the role of a physician extender in our country. PAs’ experiences are reported in the Canadian Forces (CF), where they have been employed for many years, and in Manitoba, where they are used as surgical assistants. The potential for the PA to be incorporated into our provincial health care systems will be considered in light of common barriers to Health Human Resources (HHR) strategic implementation.     

Trends in the supply of physician assistants and nurse practitioners in the United States

In 2001 an estimated 103,612 nurse practitioners (NPs) and physician assistants (PAs) were in clinical employment in the United States. The roles of PAs and NPs in providing comparable physician services are similar; they differ in that NPs are predominantly in primary care, while PAs are divided between primary and specialty care. PA and NP education processes also differ in the student pool and trends in the output. The combined number of graduates totaled 11,585 in 2001. However, the annual number of NP graduates is declining, while the number of PA graduates is increasing. These observations have implications for the future in the types of patients they see and the degree of health care services they provide.     

Skill mix: The potential for personal assistants to undertake health‐related tasks for people with personal health budgets

Personal health budgets (PHBs) are being promoted in England as expanding the benefits of choice and control to individuals with healthcare needs. National Health Service (NHS) money is provided to eligible people to use as set out in approved care plans, including direct employment of personal assistants (PAs). The government plans to increase NHS‐funded PHBs and to further introduce integrated personal budgets (IPBs). This potentially creates more demand for directly employed or self‐employed PAs with health‐related skills. The objective of this paper is to report findings from interviews with PAs (n = 105) and key informants (n = 26) from across England, undertaken between October 2016 and August 2017, about the potential for the PA workforce to undertake ‘health‐related’ tasks as facilitated by the introduction of PHBs. PAs were purposefully recruited to ensure the sample included participants from different geographical locations. Key informants were purposefully selected based on their knowledge of policy and community services. Data were analysed quantitatively and qualitatively. This paper focuses on reporting qualitative findings, which are set within the theoretical framework of normalisation process theory to explore implementation challenges of PHBs. The majority (64%) of PAs confirmed that they saw their current roles as congruent with PHBs, were willing to engage with PHBs and undertake health‐related tasks. However, 74% of PAs said they would need additional training if enacting such roles. Key informant interviews appraised the development of PHBs as complex, noting incongruences arising from NHS and social care‐funded PAs carrying out similar roles within different organisational systems. We conclude the current PA workforce is willing to take on PHB work and is likely to interweave this with work funded by PBs and self‐funding care users. Implications include the need for careful consideration of training requirements and delivery for PHB‐funded PAs.