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A Physician Assistant (PA) is a professional who practices medicine in collaboration or under indirect supervision of a physician, depending on state laws. Physicians do not need to be on-site with PAs and collaboration or supervision often occurs via electronic means when consults are necessary. ^[1] Their scope of practice varies by jurisdiction and healthcare setting.

In the United States, PAs are nationally certified and state licensed to practice medicine. A certified PA may add "C" at the end of his/her postnominal credentials. PAs are trained with the medical model and complete these qualifications in less time than a traditional medical degree. The educational model for PAs is based on the fast-tracked training of physicians during World War II. In Canada, Canadian Certified Physician Assistant (CCPA) is the credential awarded upon licensure.

The occupational title originated in the United States in the 1960s; similar occupations elsewhere include clinical officers in parts of Africa and feldshers in states of the former Soviet Union.^[2]

Several other countries including Australia and New Zealand have begun developing the new role of physician assistant or physician associate to fill actual or perceived deficiencies in rural medical care.^[3]

Overview

Physician assistants or physician associates (PAs) may:

• conduct physical examination


• order and interpret tests


• diagnose illnesses


• develop treatment plans


• coordinate care


• perform procedures


• prescribe medications


• conduct clinical research


• advise on preventive health care


• first assist in surgery^[4]

They train to work in settings such as hospitals, clinics and other types of health facilities, or in academic administration, and exercise autonomy in medical decision making. PAs assist physicians in the practice primary care or medical specialties, including emergency medicine, surgery, cardiology, etc. 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 much shorter in duration, includes all systems of the human body. Renewal of licensure is necessary every few years, varying by jurisdiction. PAs may also complete unofficial 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

In 1961 Charles Hudson recommended to the American Medical Association (AMA), the "creation of two new groups of assistants to doctors from non-medical and non-nursing personnel."^[5] 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 four former U.S. Navy Hospital Corpsmen.^[6][7] He based the curriculum of the PA program on his first-hand knowledge of the fast-track training of medical doctors during World War II.^[8] 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. And Dr. J. Willis Hurst started the Emory University Physician Assistant Program in 1967.

Beginning in January 1971,^[9] 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][5]}

By 2003 nearly 60% of physician assistants in the United States were women.^[10]:45

The PA profession has expanded globally. It can now be found in Afghanistan, Australia, Canada, Germany, Ghana, India, Israel, Liberia, the Netherlands, New Zealand, Saudi Arabia, and the United Kingdom. Many countries do not have PAs, but do have people that are employed to do similar types of work, such as clinical officers in Africa, clinical associates in South Africa,^[11]assistant medical officers in Malaysia, assistant doctors in China,^[12]Health extension officers in Papua New Guinea,^[13] and feldshers in countries formerly comprising the Soviet Union.^[2]

United Kingdom

Overview

The position of physician associate (PA) has been established in the United Kingdom since 2005. The position evolved from the position of physician assistant, developed in the US in the 1960s. In 2012, the profession voted to change the name to physician associate to distinguish the position from another one with the same name within the NHS.

Hillingdon Hospitals NHS Foundation Trust was asked to manage the recruitment of 200 physician associates who are expected to come from the US for 40 NHS trusts in September 2015.^[14]

Faculty of Physician Associates at the Royal College of Physicians of London

The Faculty of Physician Associates (FPA) is the professional body for Physician Associates working in the United Kingdom. A joint venture between the Royal College of Physicians of London and the previous professional body, the United Kingdom Associate of Physician Associates (UKAPA), the Faculty officially launched in July 2015, taking over all professional body rights from then on. The Faculty oversee the managed voluntary register, to which all practising PAs are encouraged to become a member of, as well as setting and running the National Assessment Examination and National Recertification Examination.

Scope of practice

PAs are trained under the medical model, similarly to physicians, to deliver high-quality medical care in both primary and secondary care settings. Upon graduation, PAs can specialise in many different areas of medicine, including acute medicine, primary care, emergency medicine, surgery, and psychiatry. The role of PAs has developed to provide medical services similar to those provided by house officers or senior house officers. They are trained to perform a variety of tasks including diagnosis, treatment, complex medical procedures and taking medical histories.^[15]

Voluntary register

The title of physician associate is not a protected medical profession. Hence, even if a PA has been trained in pharmacology and IRMER^[16] (ability to request radiology imaging – X-rays), they are not able to prescribe or request imaging.^[17] At present, there is no regulatory body for PAs, such as the General Medical Council (GMC) for doctors. Since June 2010, physician associates have been able to obtain membership of the Managed Voluntary Register (MVR) for physician associates.^[18] This database, run by PAs for PAs, aims to identify all qualified PAs who are able to practise in the United Kingdom. It is intended to maintain high standards in the UK.^[19] To remain on the register, physician associates in the United Kingdom are required to re-certify every 5–6 years^[20] 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.

In 2018 Matt Hancock announced the plan for PA regulation, details of which are currently being discussed by the government, the relevant options for regulatory body, HEE and the Faculty of Physician Associates at the RCP.

Training

PA training in the UK is through a 2-year accelerated medical training (MSc or Postgraduate Diploma) in Physician Associate Studies. As of 2017^[update] there are at least 32 universities offering these programs.

Barts and the London School of Medicine and Dentistry, Queen Mary University of London (QMUL) requires candidates to hold a minimum of 2:1 or above in a Life Science, Biomedical Science, or Healthcare subject. In addition, candidates must sit the UKCAT exam within 12 months of the deadline for application. Due to the competitive nature of this course, a ranking system will be used to shortlist for interview.

Aberdeen requires a science-based degree with a minimum 2:1 grade achieved and St George's requires a science-based degree with a minimum 2:2 grade achieved. This includes sport science, biology, psychology and biomedical degrees. Applicants should preferably have experience in the healthcare industry, such as a HCA or auxiliary nursing. Applications from other professionals such as nurses, radiographers and paramedics will also be considered.

University of Bradford requires a 2:1 (or above) undergraduate degree in a Life Science, Biomedical Science, or Healthcare subject. Under exceptional circumstances, extensive experience in healthcare practice may contribute and compensate if the above requirements have not been fully met.^[22]

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.^[32] It was not until 1970 that the AMA passed a resolution to develop educational guidelines and certification procedures for PAs.^[5] The Duke University Medical Center Archives had established the Physician Assistant History Center, dedicated to the study, preservation, and presentation of the history of the PA profession. The PA History Center became its own institution in 2011, was renamed the PA History Society, and is now located in Johns Creek, Georgia.^[33]

Education and certification

As of October 2016^[update], there were 218 accredited PA programs in the United States, and dozens more in development, represented by the Physician Assistant Education Association (PAEA).^[34] 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. The majority of PA programs in the United States utilize the CASPA application for selecting students.^[34] 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^[35] although unlike medical school which lasts four years plus a specialty-specific residency, PA training is usually 2 to 3 years of full-time graduate study like most master's degrees.^[36] The didactic training of PA education consists of classroom and laboratory instruction in medical and behavioral sciences, such as anatomy, microbiology, immunology, pharmacology, pathophysiology, hematology, pathology, genetics, 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 their schooling. There are residency programs in certain specialties for PAs who choose to continue formal education in such a format.^[37]

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.^[38] The Montefiore Medical Center Postgraduate Surgical Physician Assistant Program was established in 1971 as the first clinical postgraduate PA program to be recognized.^[38] Currently, there are known to be 49 programs in various specialties such as Neurology, Trauma/Critical Care and Oncology.^[39] The Association of Postgraduate Physician Assistant Programs was formed in 1988 as an instrument in the establishment of educational standards for postgraduate PA programs^[38] and currently includes 50 member programs.^[39]

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. APA stands for aeromedical physician assistant and indicates that a physician assistant successfully completed the U.S. Army Flight Surgeon Primary Course.^[40] 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 and who have passed the PANCE.

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.^[41] The content of the exam is covered in the PANCE BLUEPRINT. In addition, a PA must log 100 Continuing Medical Education (CME) hours and reregister his or her certificate with the NCCPA every two years. Every ten years (formerly six years), a PA must also recertify by successfully completing the Physician Assistant National Recertifying Exam (PANRE)^[42]

"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.^[43]

Scope of practice

Physician assistants have their own licenses with distinct scope of practice.^[44] Each of the 50 states has different laws regarding the prescription of medications by PAs and the licensing authority granted to each category within that particular state through the Drug Enforcement Administration (DEA).^[45] PAs in Kentucky, Puerto Rico and the U.S. Virgin Islands are not allowed to prescribe any controlled substances.^[46] 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.^[46]
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. The collaborating physician must also be licensed in the state in which the PA is working, although he or she may physically be located elsewhere. Physician collaboration can be in person, by telecommunication systems or by other reliable means (for example, availability for consultation). In emergency departments the laws governing PA practice differ by state, generally allowing a broad scope of practice and limited direct supervision.^[47]

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 2,000 PAs.

According to the AAPA, there are more than 108,500 certified PAs in the United States as of 2016.^[48]

In the 2008 AAPA census, 56 percent of responding PAs worked in physicians' offices or clinics and 24 percent were employed by hospitals.^[49] The remainder were employed in public health clinics, nursing homes, schools, prisons, home health care agencies, and the United States Department of Veterans Affairs^[50] Fifteen percent of responding PAs work in counties classified as non-metropolitan by Economic Research Service of the United States Department of Agriculture;^[51] approximately 17% of the US population resides in these counties.^[52]

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..."^[53] 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. The Bureau of Labor Statistics also states that there is an expected 37 percent growth between the year 2016-2026, much greater than the average job at 7 percent.

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.^[54]

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%.^[55] In 2010, CNN Money rated the physician assistant career as the number two best job in America.^[56] In 2012, Forbes rated the physician assistant degree as the number one master's degree for jobs.^[57] In 2015, Glassdoor rated physician assistant as the number one best job in America.^[58] According to the 2014 national salary survey of PAs, the mean total income for physician assistants working full-time was $112,344.^[59] Physician assistants in emergency medicine, dermatology, and surgical subspecialties may earn $100,000 to $200,000 per year.^[60]

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 U.S. government employees and their families in American embassies and consulates around the world. An important part of their jobs is to get to know what resources are available locally that they can count on in an emergency. FSHPs have some other important roles, such as advising their ambassadors on the health situation in the country and provide health education to the diplomatic community. 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.^[61]

Military PAs serve in the White House Medical Unit, where they provide care to the president and vice president and their families as well as White House staff.

PAs are employed by several organizations with the intelligence community, specifically the Central Intelligence Agency.^[62] While much of the job description is classified, they work under the Directorate of Support and are deployed to "austere environments" where they provide medical care, including trauma stabilization, and teach in the fields of survival, field medicine, and tactical combat casualty care.^[62]

U.S. Army PAs serve as Medical Specialist Corps officers, typically within Army combat or combat support battalions located in the continental United States, Alaska, Hawaii, and overseas.^[63] 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 Marine staff officer. A certificate of registry is granted through The United States Coast Guard National Maritime Center (NMC) located in Martinsburg, West Virginia.^[64] Formal training programs for marine physician assistants began in September, 1966 at the Public Service Health Hospital located in Staten Island, N.Y.^[65]

New Zealand

In February 2015, Health Workforce New Zealand completed a Phase-2 trial of PAs who worked for a period of two years (2013-2015) in four clinical settings.^[66] Specifically, the sites included one rural emergency department and three primary care settings (two rural and one urban) located on the North and South Islands of New Zealand.^[66] At conclusion of the trial, several clinics continued to employ PAs while the process of health regulation makes its way through the government bureaucracy.

Australia

In 2011, Health Workforce Australia began developing the role of physician assistant throughout the country culminating with registration and a PA Program based out of James Cook University. Despite all initial indicators showing that the new profession would be successfully integrated into the health care system, the progress has floundered resulting in the majority of PAs in Australia being unemployed.^[67]

Canada

As of October 2015^[update], there are approximately 400 PAs working in healthcare settings in Canada.^[68] The first formally trained PAs graduated in 1984 from the Canadian Forces Medical Services School at Borden, Ontario.^[69] The Canadian Medical Association (CMA) recognized the PA as a health professional in 2003.^[69]

The first civilian PA education programs were launched in 2008 at the University of Manitoba and McMaster University.^[69] In 2010, a third civilian program was launched by the Consortium of PA Education (University of Toronto, Northern Ontario School of Medicine, and The Michener Institute).

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. PAs are represented by the Canadian Association of Physician Assistants, which had formed in October 1999 as the "Canadian Academy of Physician Assistants".^[69]

India

The first PA program in India was established in 1992.^[70]

References

External links

Wikimedia Commons has media related to Physician assistants.

• Accreditation Review Commission on Education for the Physician Assistant (ARC-PA)


• Canadian Association of Physician Assistants CAPA


• American Academy of Physician Assistants (AAPA)


• National Commission on Certification of Physician Assistants (NCCPA)


• Physician Assistant Education Association


• UK Association of Physician Associates (UKAPA)


• Israeli Association of Physician Assistants


• Physician Assistant Forum