Physiatry Practice Management Resources

Family physician Harvey Frank, MD, supervises physician assistants because he loves teaching and mentoring. He also believes it is a cost-effective way for his patients to receive quality care.

General practitioner Walter Eidbo, MD, supervises physician assistants because it allows him to extend the geographical reach of his practice deep into underserved areas and increase the number of patients under his supervision. The former Army surgeon also believes teamwork enhances patient care.

St. Paul, Minn., emergency department physicians Felix Ankel, MD, and Richard Lamon, MD, supervise physician assistants because they believe having another health care professional on hand frees them for more critical cases.

Physician assistants are part of a growing cadre of allied health professionals who help physicians, hospitals and managed care payers extend care to patients in rural and inner-city areas, provide scheduling options to patients and lower staffing costs, according to a 1999 report by Health and Human Services' Health Resources Services Administration.

"Patients respect them and have confidence in them," Dr. Eidbo said. "They work rural areas where there are few doctors. They see this as a challenge and a calling. In the future, as more doctors accept them, they will become an even greater part of the medical team."

Under physician supervision, more than 50% of the nation's 41,500 PAs work in primary care settings -- the majority in family practice. Another 10% work in emergency medicine, 20% work in surgical specialties and the remainder work in a variety of other fields, according to the American Academy of Physician Assistants. Most PAs are supervised by allopathic physicians, but 25% are supervised by osteopathic physicians, AAPA said.

The first PAs were Vietnam War-era medics. During the 1960s, a handful of medical schools led by Duke University School of Medicine in Durham, N.C., began educating PAs in the medical model. During the last six years, the number of accredited PA programs has more than doubled to 122 from 55. The programs graduated 4,500 physician assistants in 2001.

Supervision arrangements vary

At the Redfield (Iowa) Medical Clinic, Dr. Eidbo supervises Ed Friedmann, a rural PA.

Like a growing number of PAs and their supervising physicians, Friedmann, a former Green Beret medic in Vietnam, and Dr. Eidbo do not share offices. Each week, Friedmann and two medical assistants see about 125 patients a week in the federally certified rural health clinic. It is located 38 miles west of Des Moines, Iowa, where Dr. Eidbo's multispecialty clinic is located.

About 25% of PAs work in rural areas, while 12% work in inner cities. These percentages have been increasing as more physicians become comfortable with off-site supervision and PAs gain more delegated prescribing rights. Only three states -- Indiana, Ohio and Louisiana -- do not allow PAs to prescribe; 41 states allow delegated controlled substance prescribing.

"The key to our relationship is trust," said Dr. Eidbo, who visits the Redfield Clinic at least once a week. "It is not 100% trust; it is 1,000% trust. You cannot work with anybody like that unless you have that level of trust."

In a typical example of collaborative care, one of Friedmann's regular patients, an 82-year-old man, came in for a visit after the sudden appearance of a black lesion on his ear. "Ed called me in to take a look," Dr. Eidbo said. "It was a malignant melanoma. We did a wide incision and took it off."

Under state laws and following AMA policy, PAs take care of patients under individual collaborative agreements with supervising physicians. Iowa law requires Dr. Eidbo to review all Friedmann's charts every two weeks, but the two generally go over charts once a week.

"I do what I am qualified for in education and training," said Friedmann, AAPA president. "Things beyond my capabilities I refer to the doctors. Patients schedule appointments with me for routine exams and problems. They primarily see [Dr. Eidbo] for surgical problems, [but also for] multiple sclerosis and rheumatoid arthritis."

In another common scenario, patients with multiple sclerosis who live in the Redfield area are treated by specialists, but come into the clinic to see Friedmann for injectable medications. "We administer that per specialist instructions," he said.

Knowing when to refer

At the Forest Lake (Minn.) Clinic, a multispecialty clinic with 18 doctors and two PAs located about 25 miles north of St. Paul, Dr. Frank supervises PA Beverly Kimball. Some 37% of PAs work in solo or group practice settings, the AAPA said.

"We collaborate a lot on cases, but she practices under my license, so every patient is my ultimate responsibility," Dr. Frank said. "Bev knows when to treat and when to refer."

Under Minnesota law, Dr. Frank is required to review a sampling of Kimball's cases every 24 hours.

"We have our own primary patients, and then we take care of emergencies as they come into the office," said Kimball, who was voted Physician Assistant of the Year in Minnesota for 2001 by the state PA chapter.

In one case, a 70-year-old woman came to the office coughing and short of breath, Dr. Frank said. "Bev had been seeing her for routine exams, but this time she felt there was a more serious problem that I needed to take a look at," he said. "It turned out I had to hospitalize [the patient] for a mild case of congestive heart failure."

Since 1991, Forest Lake has employed PAs, and, over time, most physicians have become comfortable with them, said Kathy Dill, clinic manager. The clinic is owned by 18-hospital Allina Health System and employs its physicians, PAs and other health professionals.

"We use PAs as independent practitioners under the supervision of physicians," Dill said. "They share their own panel of patients and pick up the slack when physicians are unavailable. Some doctors aren't comfortable with them. A lot depends on how good they are at mentoring and how busy their practice is."

Dill said some female patients ask for the PAs because they are women. "There are gender issues," she said. "Having PAs in the mix helps give patients quicker access to our system. We also use them as on-call backup when a physician isn't available."

Working in parallel

At Regions Hospital in St. Paul, Minn., Steve Wandersee, the lead emergency medicine PA, works alongside physicians, nurses and medical students. Some 26% of PAs work in hospitals.

"The [eight] PAs work in parallel with our residents," said Dr. Ankel, emergency medicine residency director, during a Wednesday evening shift in June. "As residents rotate through the department, they learn to work with PAs and nurses. It is a good educational experience."

When Wandersee first started at Regions in 1984, nobody knew what a PA was or what they did. "Now we are accepted members of the health care team," he said.

Like attending physicians and residents, Wandersee waits for emergency cases to be wheeled in from ambulances or admitted as walk-ins by triage nurses. "If a patient comes in with a chest pain, they get bumped up to the critical care unit," he said.

Using a computer at the doctor's work station, Wandersee checks the "who's next board" that lists all the patients the nurses have triaged and their symptoms. "I take the next one on the list," he said.

Next up on the board is a 77-year-old man with a 103-degree temperature and a history of heart failure. Brought into the hospital from a nearby nursing home, the patient had vomited once earlier that day and was in a mild state of confusion. Wandersee ordered chest x-rays, blood tests and an urinalysis. Within 15 minutes, Wandersee and Kathleen Neacy, MD, chief of the critical care unit, were examining the chest x-ray.

"This doesn't look nice to me," said Dr. Neacy. "There's fluid in there and wedging at his lung bases." The two decided to wait for the lab test results before committing to a course of treatment. After less than 70 minutes, the lab results came back: white blood count above 20,000 and a urinary tract infection. "We will put him on Cipro [ciprofloxacin] and admit him," Wandersee said.

Five years ago, PAs at Regions performed intubations, Wandersee said. But when Regions added an emergency medicine residency, their workload changed.

"The residents have to do so many procedures that it takes away some of our responsibilities," Wandersee said. "There still is plenty of work for everybody."

Additional Information

Training. Training of physician assistants follows the medical model. After about three years of what amounts to "pre-med" studies, PAs train in clinical rotations in medical and surgical specialties alongside medical students at hospitals and clinics.
Coursework. At least two years of college courses in basic science and behavioral science. About one-third of PA schools now require a bachelor's degree for admission and grant master's degrees upon completion. The typical PA student is at least 28 years old, has a bachelor's degree and four years of health care experience.
Program length. PA programs are 25 to 27 months long, which includes 2,000 hours of supervised clinical practice prior to graduation. During their "internship," PAs rotate through medical and surgical specialties (family medicine, internal medicine, obstetrics and gynecology, pediatrics, general surgery, emergency medicine and psychiatry).
Certification. Some states and employers require PAs to be certified. To become certified, PAs are required to complete 100 hours of continuing medical education every two years and take a recertification examination every six years. PAs do not have specialty boards.

Source: American Academy of Physician Assistants

Pertinent PA facts

• Physician assistants work an average of 44 hours a week compared with 57 for physicians.
• PAs earn an average of $68,000 a year compared with family physicians, who earn an average of about $141,000. The average age of a PA is 41; 55% are female and 45% are male.
• Medicare covers medical services provided by PAs at 85% of the physician fee schedule. Medicaid programs reimburse PAs for their services at 75% to 100% of physician rates. Private insurers generally cover medical services provided by PAs when they are included as part of the physician's bill or as part of a global fee for surgery. AMA policy calls for "reimbursement for services of a physician assistant be made directly to the employing physician."
• Under physician supervision in medical practices, PAs perform examinations and procedures, order tests, provide follow-up care and help with the coordination of care for patients with complex illnesses. In surgical practices, PAs take preoperative histories and physical examinations, order tests and help surgeons with postoperative care.

Source: American Academy of Physician Assistants

Links

American Academy of Physician Assistants

AAPA strategic plan, "Into the Future: Physician Assistants Look to the 21st Century," developed for the HHS Health Resources and Services Administration's Bureau of Health Professions in April 1999 (http://www.aapa.org/strategicplan.html)

AMA policy on physician assistants and nurse practitioners (H-160.947)

AMA principles on supervision of advanced practice nurses in an integrated practice (H-360.987)

AMA policy on allied health professionals policy (E-3.03)