The Physician - PA Team
More than 30 years ago a group of physicians, looking critically at America’s health care needs, envisioned a new type of health professional. Their hypothesis was that physicians could treat more patients, utilize their time and talents more wisely, and provide better care, if they worked with assistants who were trained in medicine and practiced with physician supervision. This idea has grown into the health profession known as physician assistants (PAs).
The visionaries of the PA role were right. A physician can more effectively care for patients when working as part of a physician-PA team. The efficiency of this model has led to its utilization in all medical and surgical specialties. The physician-PA team is effective because of the similarities in physician and PA training, the PA profession’s commitment to practice with supervision, and the efficiencies created by utilizing the strengths of each professional in the clinical practice setting.
Physician Assistant Education - Training in the Medical Model
The relationship between PAs and physicians begins in PA school where physicians, PAs, and others provide instruction in a curriculum following the medical school model. PA students typically share classes, facilities, and clinical rotations with medical students. Applicants to PA programs must complete at least two years of college courses in basic science and behavioral science as prerequisites to PA training. This is analogous to pre-med studies required of medical students. The mean length of PA education programs is 26 months1. Students begin PA programs with a year of basic medical science courses (anatomy, pathophysiology, pharmacology, physical diagnosis, etc.). Following the basic science and medical science classroom work, PA students enter the clinical phase of training. This includes classroom instruction and clinical rotations in medical and surgical specialties (family medicine, internal medicine, obstetrics and gynecology, pediatrics, general surgery, emergency medicine, and psychiatry). PA students complete 2,000 hours of supervised clinical practice prior to graduation. 2
Because they train using similar curriculum, training sites, faculties and facilities, physicians and PAs develop a similarity in medical reasoning during their schooling that eventually leads to homogeneity of thought in the clinical workplace. 3
Commitment to Team Practice
The American Academy of Physician Assistants (AAPA) is the national professional society for PAs. In this capacity the AAPA is the voice of over 60,000 physician assistants in the United States.
The PA profession remains committed to the concept of the supervising physician-PA team. This is reflected in the AAPA's description of the profession:
Physician assistants are health professionals licensed or, in the case of those employed by the federal government, credentialed, to practice medicine with physician supervision. 4
The commitment to practicing as part of a physician-directed team is clearly stated in the AAPA policy on team practice:
The AAPA believes that the physician-PA team relationship is fundamental to the PA profession and enhances the delivery of high-quality health care. As the structure of the health care system changes, it is critical that this essential relationship be preserved and strengthened. 4
Other organizations also have policies supporting team practice. In 1995 the American Medical Association adopted "Guidelines for Physician/Physician Assistant Practice." The 10 guidelines describe the roles of the physician and the PA, including:
The role of the physician assistant(s) in the delivery of care should be defined through mutually agreed upon guidelines that are developed by the physician and the physician assistant and based on the physician’s delegatory style. 5
The American Academy of Family Physicians recognizes the value of team practice. AAFP policy states:
The AAFP recognizes the dynamic nature of the health care environment and the importance of an interdependent team approach to health care that is supervised by a responsible licensed physician. 6
In 1998 the Pew Health Professions Commission completed a two-year study of the PA profession. In its 12 recommendations for PA deployment, the report supports the continuation of the traditional physician-PA team, and suggests its use as a model in an evolving system:
The traditional relationship between PAs and physicians, the hallmarks of which are frequent consultation, referral, and review of PA practice by the supervising physician, is one of the strengths of the PA profession. The characteristics of this relationship are also considered to be the elements of professional relationships in any well-designed health system. 7
The Physician - PA Team - Synergy in Clinical Practice
In all states, the District of Columbia, and Guam, physicians may delegate to PAs those medical duties that are within the physician’s scope of practice, the PA's training and experience, and state law.
Such duties include performing physical examinations, diagnosing and treating illnesses, ordering and interpreting lab tests, assisting in surgery, and making rounds in nursing homes and hospitals. In 47 states plus the District of Columbia and Guam, physicians may delegate prescriptive privileges to the PAs they supervise.
Effectively utilizing the skills of each provider results in appropriate and efficient care and high levels of patient satisfaction.
A study conducted by the Rand Corporation found that PAs can perform most of the routine functions in a general medical practice and are widely accepted by patients. 8 PAs are able to handle common patient complaints, follow-up visits, and patient education and counseling. PAs are responsible for the day to day care of patients, turning to their supervising physicians when faced with cases requiring more advanced medical knowledge.
In many primary care practices the presence of PAs allows patients to be seen promptly, knowing that their routine problems will be handled effectively and that the expertise of the physician is available if needed. Physicians are able to focus on complicated patient problems and allow appropriate time for their care.
In surgical practices, the presence of PAs enables surgeons to delegate the performance of preoperative histories and physical examinations, the ordering and compiling of necessary tests, and part of the postoperative care. In addition, PAs are excellent assistants in surgery. The familiarity and experience of the physician-PA surgical team results in efficiency in the OR that can reduce operative and anesthesia times.
Physician-PA teams are also effective in medical and surgical subspecialty practices, where PAs perform examinations and procedures, order tests, provide follow-up care, and help with the coordination of care for patients with complex illnesses.
Studies have shown that PAs, practicing as part of a supervising physician’s team, provide high quality health care. A 1994 federal study of state practice environments reported: "Within their areas of competency, and within appropriate training and supervision, these practitioners may provide medical care similar in quality to that of physicians at less cost."9 The AMA’s Socioeconomic Monitoring System of approximately 4,000 practices found that 56 percent of group practice physicians and 39 percent of solo practice physicians employ nonphysician providers, including PAs. "The data show that employing nonphysician providers enhances physician productivity," according to the survey report. 10
Numerous individual reports describe the value of the physician-PA team. Writing in the journal Family Practice Management, a family physician describes the physician assistant’s role in the practice: "The PA makes himself invaluable by smoothing the ebbs and flows of our daily workload…. We wonder how any practice can thrive without one." 11
- Nineteenth Annual Report on Physician Assistant Educational Programs in the United States, 2002-2003. Alexandria, VA. Association of Physician Assistant Programs.
- Eleventh Annual Report on Physician Assistant Educational Programs in the United States, 1994-95. Alexandria, VA. Association of Physician Assistant Programs.
- White GL, et al. Physician assistants and Mississippi. J Miss St Med Assn 1994;25:353.
- American Academy of Physician Assistants. 2002-2003 Policy Manual. Alexandria, VA.
- American Medical Association. Guidelines for Physician/Physician Assistant Practice. 1998 Policy Compendium. Chicago, IL.
- American Academy of Family Physicians. 1997-1998 AAFP Reference Manual: Selected Policies on Health Issues. Kansas City, MO.
- The Pew Health Professions Commission. Charting a Course for the Twenty-First Century: Physician Assistants and Managed Care. San Francisco. UCSF Center for the Health Professions. 1998.
- Jolly DM. Patients’ Acceptance of Physician’s Assistants in Air Force Primary Medicine Clinics. Santa Monica. RAND Corporation. 1980.
- Sekscenski ES, Sanson S, Bazell C, et al. State practice environments and the supply of physician assistants, nurse practitioners and certified nurse-midwives. New Eng J Med 1994;331:1266.
- Gonzalez, ML, ed. Socioeconomic Characteristics of Medical Practice 1995. Center for Health Policy Research, American Medical Association. Chicago, IL.
- Iliff, D. "Solo practice: the way of the future." Fam Practice mgmt 1998; 5:16.
AAPA Issue Brief: The Physician-PA Team