If you prefer to view this article in PDF form, click here.

The right DNA

Stephen C. Crane, PhD, MPH

The author is Executive Vice President and CEO of the AAPA.

As I travel around the country as AAPA executive vice president/CEO, I marvel at how the PA profession has progressed and thrived since I first became involved with it in the early 1970s. Despite the many changes in health care over the years, the demand for PAs remains strong. The proportion of PAs choosing to practice in nonprimary care specialties continues to increase (see Table 1). The growing output of PA programs, combined with a low rate of PA retirements and deaths, means that by 2010 there will be more than 87,000 people eligible to practice as PAs in the United States. Today, several nations are looking to adopt and adapt the PA concept to their own health care system needs, making quite real the vision of the profession to be worldwide leaders in health care.

Perhaps the most striking finding from AAPA’s surveys is how highly satisfied PAs are with their chosen profession—89% definitely or probably would become a PA again.¹ This is a phenomenal statistic, in particular when compared to surveys of other professions.

The PA DNA

What accounts for these remarkable results? I believe that it is the DNA of the PA profession.

All the information necessary to produce a human being is contained in a single strand of DNA. I believe the PA profession also has a DNA, and its four “nucleotides” are preparation for practice through broad training in the disciplines of medicine and surgery, lifelong learning and continued growth in scope of practice, team orientation to the delivery of health care services, and an emphasis on caring as well as curing.

Preparation for practice

Preparation for practice through broad education in the various disciplines of medicine and surgery means that upon graduation, PAs can search out specialty areas and work sites throughout the health care system. The vision of the profession’s founder, Eugene Stead, MD, was that PAs and physicians should receive the appropriate education and hands-on experience to treat the majority of patients in a given practice setting. Dr. Stead rejected the notion that the educational system should—or could—prepare new health professionals for every aspect of practice. The breadth and depth of their knowledge grows with time, experience, and the tutelage of other health professionals.

How well these concepts have served the PA profession! After 2 years of very intense education, PAs are successfully prepared to begin practicing alongside their supervising physicians. One universal option is the flexibility to change medical and surgical specialties during their career. Thus, as the needs of the health care system have changed, PAs have been able to move effectively into many different roles.

For instance, more and more PAs are choosing to join surgical practices. They do so without the need for additional formal education or certification beyond the PANCE. Clinicians educated in “silo-type” professions could not have moved as nimbly to fill the demand for qualified health professionals in surgical practice.

Clearly the adaptability and flexibility of the profession assures PAs of an ever-expanding set of job opportunities. These opportunities contribute directly to the satisfaction AAPA observes for the profession as a whole. From society’s perspective, PAs are a great value precisely because they can move quickly to expand the supply of physician services when and where this is needed without much additional preparation or cost. PAs also stay in practice as PAs. Ninety-three percent of all respondents to 2004 AAPA’s annual PA census survey were still in full or part-time clinical practice.² PAs provide a great return on society’s investment in their education. These facts alone will assure the continued success of the PA profession.

Lifelong learning

The concept of lifelong learning speaks to the strength of the PA concept. The needs of the health care system and the interests of a practitioner do not remain the same over time. As the knowledge and skills of a PA increase with experience, continuing education, and additional training, more functions can be delegated safely to that PA. The supervising physician remains responsible overall for which functions are delegated, thus assuring both that the quality of care provided by the PA remains high and that the standard of care provided by the PA is that of the supervising physician.

Lifelong learning is a key part of the PA DNA. For example, most PAs enter surgical practice with fundamental skills and knowledge. Over time, they learn from their supervising physicians and others in their practice. PAs end up practicing the type of surgery that their supervising physicians, and their employers, are most comfortable having them practice. No process of specialty certification can substitute for this hands-on approach that relies appropriately on demonstrated competence. The skills and knowledge learned can be taken to new situations and adapted very quickly. What wonderful flexibility this is for the PA, the supervising physician, and the health care system.

Team practice

The days of the solo, independent, unconnected practitioner are long over. In many ways, the PA profession pioneered modern, team-based practice through reliance on formalized systems of delegation of function, supervision of practice, and lifelong learning. Supervision itself is not so much about hierarchy of authority as it is about establishing and maintaining communication, coordination, and continuity of care. These three elements are most important cornerstones of any effective health care system. Other health professions can learn much about team practice from the physician–PA model.

Caring as well as curing

Numerous studies suggest that patients appreciate their relationships with PAs.^3,4 Whether it is that PAs do not wear the mantle of “doctor” and seem more approachable, that they are more plainspoken, or that they simply have learned how to translate “medicalese” into more easily understood words, PAs communicate well with patients.

PAs often serve as the intermediary between the patient and the rest of the health care system. They focus on issues such as prevention and adherence, which help to make treatment for acute conditions less necessary on the one hand and more effective on the other. Their rapport with patients serves to minimize potential malpractice problems as well. PAs truly are high touch as well as high tech.

The challenges ahead

Over the past 40 years, the PA profession has shown impressive resilience and adaptability to advances in medical science, changing approaches to the organization and delivery of health care services, and changing views of the adequacy of the supply of health services. The single strand of PA DNA mitigated the effects of these changes and resulted in myriad forms of PA practice that have survived many health system challenges. Perhaps most important are the flexibility and mobility of the profession.

These contribute to greater access by allowing easy expansion of the supply of medical and surgical services, as provided by physician–PA teams. These same characteristics help to control the cost of care by minimizing unnecessary or wasteful education and specialty certification, while increasing the efficiency and effectiveness of the care provided by physicians. The team approach helps to promote quality of care at all levels through better communication and evidence-based practice.

Flexibility and mobility are even more important today. A growing and aging population, increasing rates of retirement for physicians, and their unwillingness to work the hours worked by previous generations of physicians all have combined to produce a shortage of physician services that is expected to extend through the next several decades.⁵ The increasing rate of specialization and the difficulty of recruiting physicians into primary care practice will further exacerbate these problems.⁶ Just as in the mid-1960s, when the nation also faced a shortage of physician services and rising health care costs, the PA profession stands poised to help address today’s crisis.

Preserving and protecting

What will it take to assure that the promise of the PA profession will be realized?

First, PAs must continue to work with physician colleagues and others to demonstrate that PAs are as committed as ever to the team practice of medicine. With the growing complexity of medical science, the increasing challenge of caring for patients with chronic illness, and the interdependence of all health professionals, the physician–PA team represents a model for the delivery of health care services that fits the needs and technology of today as well as tomorrow.

Second, the profession must assure a continuing stream of qualified faculty. This is necessary not only to assure the continuing quality of the next generation of PA students, but also to better meet the demand for PAs who can assist in delivering more physicians services.

Third, the profession must convince health workforce planners and policy-makers to think in terms of “services” and not “professionals.” A recent workforce report by the American Academy of Family Physicians said it well:

Fourth, the profession must absolutely assure the continued mobility and flexibility of PAs. This means that we must not block their entry into specialty areas or work settings by requiring additional education or erecting bureaucratic paper barriers. We must continue to emphasize demonstrated competence in practice rather than certificates of course completion.

Finally, the PA profession should play a much greater role than it has in assuring the safety and quality of health care services. The phrase reliability of health care increasingly is being used to represent the dual concerns of safety and quality. Reliability also captures the essence of the PA profession’s contribution to health services delivery. Just as PAs are poised to address the problem of the rising cost and increasing shortage of health services, they also are in a perfect position to help assure and increase the reliability of health care services in meeting the changing needs of an aging population.

The right DNA

The PA DNA is unique, it is special, and it is right. The profession must continue to keep PA education at the level and length necessary to produce a flexible health professional in medicine and surgery. The current educational model and length of training have worked very well, and there is no need to change them. The profession must continue to emphasize lifelong learning and expansion of PA functions based on demonstrated competence. The mobility of PAs, and the adaptability of the profession to quickly and effectively meet society’s most pressing health care needs, must not be compromised by the establishment of multitudes of individual certification requirements for practice. PAs not only must practice team care, but they also must advocate—with the support of the physician community—for its further development and use in every part of medicine and surgery. When education and demonstrated competence and team practice flow together in the health care setting, cures are produced in a caring fashion. It is incumbent on PAs as health professionals, and on AAPA as their professional organization, always to put the interests of patients ahead of professional interests and concerns. After all, that is the core of the PA DNA. 

REFERENCES

	1.	Nine out of 10 PAs would choose same career path. AAPA News. August 15, 2002;23(14):1.
	2.	2004 AAPA Physician Assistant Census Report. Available at: http://www.aapa.org/research/04census-intro.html. Accessed April 20, 2005.
	3.	Perry K. Why patients love physician extenders. Medical Economics. August 21, 1995:58-67
	4.	Hooker R, Potts R, Ray W. Patient satisfaction: comparing physician assistants, nurse practitioners, and physicians. The Permanente Journal. 1997;1(1):38-41.
	5.	Croasdale M. Physician shortage? Push is on for more medical students. AMNews. March 14, 2005. Available at: http://www.ama-assn.org/amednews/2005/03/14/prl10314.htm. Accessed April 19, 2005.
	6.	Croasdale M. Work force study tackles specialty vs. primary care. AMNews. April 11, 2005. Available at: http://www.ama-assn.org/amednews/2005/04/11/prsb0411.htm. Accessed April 20, 2005.
	7.	Green LA, Dodoo MS, Ruddy G, et al. The Robert Graham Center: Policy Studies in Family Medicine and Primary Care, American Academy of Family Physicians, in collaboration with The Center for Health Professions, University of California, San Francisco. The Physician Workforce of the United States. A Family Medicine Perspective. October 2004. Available at: http://www.graham-center.org/PreBuilt/physician_workforce.pdf. Accessed April 19, 2005.

© 2007 Haymarket Media, Inc. and the American Academy of Physician Assistants. All rights reserved.
Use of jaapa.com subject to License agreement. Please read our Disclaimer and Privacy policy.