LATELY, THERE’S BEEN A lot of talk about the growing shortage of doctors in a variety of specialty fields. From primary care to rheumatology and every other corner of medicine in between, it seems there are just not enough physicians available to treat every patient who wants and needs care. Fueled by an aging population, these shortages are projected to get worse in coming years. New data released in April 2018 by the American Association of Medical Colleges notes that the shortage could climb as high as 120,000 doctors by 2030.
The good news is that physicians aren’t the only clinicians who can care for patients. Other members of the health care team are able to manage many aspects of patient health, and physician assistants may be able to help ease the growing shortage of physicians in primary care and other fields.
To understand how physician assistants differ from doctors and nurse practitioners, we offer answers to questions such as:
- What are physician assistants?
- How are PAs trained?
- What’s the difference between physician assistants and nurse practitioners?
- What do physician assistants do?
- Can PAs ease the physician shortage?
- Can PAs offer high-quality health care?
When You Disagree With Your Doctor
What Are Physician Assistants?
PAs are clinicians trained to at least the master’s degree level using what’s essentially a condensed medical school model, explains Jonathan Sobel, president and chair of the Board of Directors of the American Academy of PAs. “PAs came out of a concept from Dr. Eugene Stead Jr. at Duke University in the 1960s. He had the concept of a fast-track clinician who could fill shortages predicted in the physician arena at that time as well. He took returning military corpsmen and trained them” to run specialty units at Duke. The two-year program graduated its first class of PAs in 1967. “The education model was standardized,” and the profession expanded across the country.
Dawn Morton-Rias, president and CEO of the National Commission on Certification of Physician Assistants, the only organization that certifies PAs in the United States, says that “PAs are health providers educated in the medical model. We’re educated like physicians,” in that PAs have a four-year college degree before entering a PA program.
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How Are PAs Trained?
Because PAs are clinicians trained to at least the master’s degree level, they first need a bachelor’s degree. Then, they attend PA school. “There are more than 250 highly competitive PA programs and they all require a bachelor’s degree for entry,” Sobel says. Typically, this degree will be in a health or basic sciences field, so when they enter PA school, these students have a comparable background to students entering medical school. “If you lined them up to med students, you would see they’d be very similar if not identical,” he says.
In addition to having the right educational background, Sobel says “PA students bring with them an average of more than 3,000 hours of direct patient contact experience that they’ve gained working as paramedics, medical assistants, medical scribes nursing assistants, athletic trainersand all types of other health care experiences.”
PA school takes an average of 27 months to complete, and these programs involve intensive, full-time study. The first year or so is spent in the classroom, and “after that, more than 2,000 hours are spent doing clinical rotations through all the different areas of medicine,” Sobel says, including pediatrics, internal medicine, orthopedics, mental health care and so on. Just like physicians, PAs learn about all the different aspects of medicine and medical care. “Those rotations give the PA a broad base, and that’s important because when the PA graduates they’re trained as a generalist and they’re able to go out and fill those gaps in health care wherever there’s a need.”
After completing their education, PAs enter the workforce and continue learning on the job in an apprenticeship model. Sobel says PA fellowships and residencies that provide additional specialty training to PAs are cropping up and usually last about a year, but “that’s an optional approach and different from the apprenticeship model” that is more commonly how PAs continue to learn and grow as professionals.
“The vast majority of PAs really become specialized in a particular discipline from years of experience in an apprenticeship-type of model where they’ve worked with a team,” Morton-Rias says. “Depending on their discipline, (PAs can) really refine their skills through that direct practice management experience and over time have acquired greater degrees of autonomy and responsibility as their knowledge and skills become enhanced.”
What’s the Difference Between Physician Assistants and Nurse Practitioners?
PAs and NPs got their start around the same time, and while they are sometimes lumped together and address similar care needs, NPs and PAs are different types of providers. “At the practice level, there’s likely to be more similarities than differences between PAs and NPs,” Sobel says, but there are two key differences: “PAs are educated in general medicine, which offers a very comprehensive view of all aspects of medical care, whereas NPs choose a population focus. So, you’ll see pediatric NPs or women’s health NPs or gerontology NPs, whereas PAs remain in that general model.”
Secondly, because the PA curriculum was designed as a fast-track medical training program, “it’s modeled on medical school education. NPs are trained in the advance practice of nursing, which is why you’ll hear them referred to as advanced practice registered nurses.” This difference in educational philosophy between the medical and nursing models may not be all that noticeable to the average patient who simply needs to see a health care provider for help managing a common problem such as diabetes.
Being educated in the medical model means “our focus, like for physicians, is to diagnose, treat and manage disease,” Morton-Rias says. “While we do provide health promotion and disease prevention and we do provide patient education and counseling, our first and foremost responsibility, like physicians, is to diagnose, treat and manage. That’s a little different from a nursing philosophy or a nursing model where the care is more supportive, related to health promotion and disease prevention.”
In addition, to become a nurse practitioner “you have to have been a nurse first, whereas for PAs they come into PA school looking academically very much like pre-med students,” Morton-Rias says. To get into PA school, students need to have some clinical experience, and many would-be PAs have also worked as nurses, nursing assistants, paramedics, EMTs, lab technicians, radiography technologists, pharmacy techs or elsewhere in health care prior to entering PA school.
All PAs who wish to practice must first become certified by the NCCPA and then apply for a license in their state. Practice laws governing what PAs can do vary from state to state, but “all states require that they have their certification in order to obtain a license to practice medicine as a PA,” Morton-Rias says. Once they’re licensed, “PAs provide 80 to 90 percent of the services ordinarily provided by physicians,” she says.
“For the average person who goes in to see a provider, you’re not going to notice much of a difference whether you’re seeing a physician or a PA or perhaps even an NP,” Sobel says, “because PAs do the same type of work. It’s very similar to what you’re getting from your physician provider that you can expect to receive from your PA provider.”
This means “we obtain patient histories. We perform physical exams. We order and interpret lab tests. We make diagnoses. We prescribe medications. We assist in surgery. We work in the emergency room. We treat and manage patients in every clinical setting in which patients are seen,” Morton-Rias says, adding that “on the rare occasion where the patient has a very complex or unique situation or condition presenting in an unusual way, then we consult with physicians on care and management of that patient. PAs work everywhere.”
This flexibility means that PAs are increasingly being viewed as “a big part of the solution to the physician shortage,” Sobel says. But he says not all PAs are able to work to the full extent of their training and experiences because of “outdated state practice laws and regulations” in some states. “For example, many dictate how PAs and collaborating physicians work together, including where and how often the physician must consult with each PA and how many PAs the physician can collaborate with. And over time those requirements have made it difficult for PAs to really practice at the top of their education and experience.” Instead of setting stringent parameters at the state level, Sobel says PAs, physicians and patients would be better served if those decisions were handled at the practice level.
“In every medical setting, there’s going to be different challenges and different patient populations and different levels of comorbidities. Enabling PAs and physicians and other members of the health care team to make those decisions at the practice level will allow health care teams to better harness the time and talents of each clinician and ultimately increase the access for patients and the quality of outcomes.”
Still, PAs typically work in a team-based environment alongside physicians, NPs, other PAs and other providers. “The PAs will see patients that they’re comfortable handling and there may be a clinical question that comes up where they feel that they want to bounce that off other members of the team, which is often the physician. Similarly, the physician may feel that they want to get the PA’s opinion on something,” Sobel says. This collaborative approach may be helpful for getting the best care, he says, because “medical knowledge is doubling so fast that it’s really impossible for one person to keep abreast of it. By 2020, it’s projected to double every 73 days, so I would certainly be a proponent of the team approach.”
Can PAs Ease the Physician Shortage?
Today, Sobel says there are more than 123,000 PAs practicing in the U.S., “and that number is expected to increase by 37 percent between 2016 and 2026,” with 24 percent of those PAs expected to practice in primary care settings. “Sixteen percent are going to practice in rural health care settings across the country. It’s definitely going to be making an impact on that shortage,” Sobel says.
And visits to these providers are on the rise. A report released last month by the Health Care Cost Institute shows that, between 2012 and 2016, visits to nurse practitioners and physician assistants soared 129 percent, while office visits to primary care physicians dropped 18 percent. The report doesn’t separate the data on visits to NPs compared to PAs, but it’s clear that visits to these similar but distinct types of providers are on the rise.
The NCCPA reports that in 2017, the average salary of certified PAs was $107,718 and the median salary was $105,000. PAs who work in pathology and dermatology reported the highest wages. “The average salary has increased 12.7 percent in the last five years,” which may also be helping to drive the growth of this profession. U.S. News ranked it as a top health care job.
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Can PAs Offer High-Quality Health Care?
Studies have shown that PAs are able to deliver high-quality health care to patients, particularly when they’re working in teams. A 2016 study conducted by the Peterson Center on Healthcare and Stanford University’s Clinical Excellence Research Center ranked the best primary care practices in the country and found that the top practices “ensure PAs can work to the full extent of their education and experience,” Sobel says.
Another study, published in 2017 by the American Journal of Medicine found that after four years of consistent care, outcomes for diabetes patients at the Veterans Health Administration were similar whether patients were treated by a PA or a physician. And a 2018 study in the Annals of Internal Medicine “found no significant clinical variation in the care and treatment of diabetes when provided by NPs, PAs or physicians,” Sobel says.
“Certainly, around some of the biggest diseases that are plaguing our country and our population, PAs and NPs are able to make that impact that we’re looking for and that’s important to note. We’re positioned as a good alternative and complement to the physician workforce across all disciplines,” he says.