The occupation of physician assistant (PA) came into being during the 1960's, when physicians were in short supply. Additional education enabled medical corpsmen trained during the Vietnam conflict, as well as some nurses and others with patient-care experience, to relieve physicians of many essential but time-consuming tasks. PA's interview patients, take medical histories, perform physical examinations, order laboratory tests, make tentative diagnoses, and prescribe appropriate treatments. Studies show they have the ability to care for 8 out of 10 people who visit a family practitioner's office in any one day. PA's however, always work under the direction of a licensed "supervising physician." Alternative titles sometimes used by these workers are MEDEX and physician associate.
About half of all PA's assist physicians in such specialty areas as pediatrics and surgery. They perform routine procedures such as physical examinations, provide postoperative care, and assist during complicated medical procedures such as cardiac catheterization. These specialist PA's include child health associates, orthopedic physician assistants, urologic physician assistants, surgeon assistants, and emergency room physician assistants.
Physician assistants work in the same places as physicians. Hospitals, clinics, and physicians' offices usually provide a comfortable, well-lighted environment, although PA's must often stand for long periods and do considerable walking.
The workweek and schedule vary according to the setting. Some emergency room PA's work 24-hour shifts twice weekly, and others work three 12-hour shifts each week. The workweek of PA's who work in physicians' office may include some night office hours or early morning hospital rounds to visit patients. PA's in clinics usually work a 5-day, 40- hour week. Employment
Physician assistants held about 48,000 jobs in 1990. PA's most commonly work for physicians in office-based medical practices; others work in hospitals. A small but growing number work for health maintenance organizations (HMO'S), other prepaid health plans, or clinics.
an estimated 40 percent of all PA's provide health care to communities having fewer than 50,000 residents and where physicians may be in limited supply.
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In the early years of the occupation, informal training was not uncommon, but today, nearly all States require that new PA's complete an approved program. Approximately 16,500 PA's had completed such training programs by 1984. Fifty-two educational programs for primary care physician assistants and three programs for surgeon assistants were approved by the Committee on Allied Health Education and Accreditation (CAHEA) of the American Medical Association.
Admission requirements vary, but 2 years of coursework at the college level in science or one of the health professions is usually the minimum requirement. About half of all applicants hold a bachelor's or master's degree but fully one-third hold no formal degree beyond high school.
A background that includes "hands on" health care experience is an important qualification for entry to these highly competitive programs. Most programs require applicants to have experience working directly with patients. Jobs that provide the requisite clinical experience range from medical technologist to registered nurse. The type of job is not particulary important; what counts is a background in direct patient contact.
Education programs are generally 2 years in length, although some are longer and a few are shorter. Most PA programs are located in medical schools, schools of allied health, or 4-year colleges; a few are located in community colleges or are hospital based. Regardless of the institutional sponsorship, most accredited PA programs have clinical teaching affiliations with medical schools or medical school faculty.
PA education begins with a classroom or didactic phase that lasts 6 to 24 months. Classroom instruction includes human anatomy, physiology, microbiology, clinical pharmacology, applied psychology, clinical medicine, and medical ethics. During the program's last 9 to 15 months, students do supervised clinical work designed to develop practitioners's skills. Clinical training begins with a series of clinical practice assignments or rotations. These rotations include family practice, inpatient and ambulatory medicine, general surgery, obstetrics and gynecology, emergency medicine, internal medicine, psychiatry, and pediatrics. Sometimes, one or more of the rotations are served under the "preceptorship" or supervision of a physician who is seeking to hire a PA. This learning experience often leads to a permanent position.
The number of PA programs that award a bachelor's degree has been growing, and currently about two-thirds of the programs do so. Most of the remaining programs offer a certificate and/or associate degree; two lead to a master's degree.
MEDEX programs, which last about 18 months, are slightly shorter than other PA programs. MEDEX programs are designed for people who have had extensive patient-care experience, usually as medical corpsmen or registered nurses. This background allows for a shorter period of classroom training and increased emphasis on clinical experience. MEDEX students usually gain most of their supervised clinical experience working with the physician who will hire them upon graduation.
Postgraduate education for PA's, term the "PA residency," is a recent development. Residency programs, as yet unaccredited, are available in emergency medicine, general surgery, neonatology, and occupational medicine.
State laws and regulations govern the use of the title "physician assistant" and the scope of PA practice in all but a few States. Most States require that PA's be graduates of accredited educational programs, and 39 States require that PA's be certified by the National Commission on Certification of Physician Assistants, (NCCPA).
The PA's scope of practice--the duties he or she may perform--is determined in some States by the supervising physician and in others by the State's regulatory agency. There is considerable variation in State laws and regulations, and changes commonly occur. Aspiring PA's should investigate the laws and regulations where they wish to practice.
Individuals planning a career as a physician assistant should be conscientious and willing to study a great deal throughout their career to keep up with medical advances. They should exhibit leadership, self-confidence, and emotional stability. A pleasant personality, patience, and the ability to deal with all kinds of people are essential.
Formal lines of advancement have not evolved within this young profession. There are no head PA's in hospitals or nursing homes as there are head nurses; by the very nature of the profession, individual PA's are supervised by physicians. Since a supervising physician shares responsibility for the quality of care rendered by the PA, this relationship must be a close one.
Some PA's advance after additional education to practice in a specialty area such as emergency medicine; others advance with experience to added responsibilities and higher earnings, although earnings generally level off within 7 or 8 years after graduation.
Employment of PA's is expected to grow much faster than the average for all occupations through the year 2000 due to the anticipated expansion of the health services industry and greater reliance on PA's to provide primary care and assist with medical and surgical procedures. Prospects for newly trained PA's appear excellent since educational programs are not expected to produce enough PA's to fill all job openings.
Over the past decade, as the number of PA's has grown, their role in delivering health care has expanded as well. In the early years, PA's worked mostly in physicians' offices and rural clinics. Although many jobs for PA's continue to be found in private practice, particularly in family practice, PA's work in a variety of settings.
A trend toward practice in institutions is taking hold. A growing number of PA's provide care to medically undeserved populations--prison inmates or residents of nursing homes and other long-term care institutions, for example. In addition, hospitals are an increasingly attractive workplace for PA's. Hospitals hire PA's to replace resident physicians and foreign medical graduates as the number of surgical residency programs is reduced and fewer foreign graduates enter the country.
Follow-up data reveal that nearly all newly trained PA's find work. New graduates may have to accept jobs in medically underserved areas, but they do not view this as a hardship. Most PA students report a preference to practice in a small city or town.
Long-term prospects for PA's are difficult to assess, largely because of unresolved issues in payment for their services. Restrictions on health insurance, Medicare, and other kinds of third-party reimbursement for services provided by PA's is one of the most important questions clouding the profession's future. Studies have established that substituting PA's for some physicians can lower costs without reducing the quality of care. However, the majority of health insurance programs do not pay for services performed solely by a PA. Uncertainty regarding payment makes some physicians reluctant to hire PA's.
Another unsettling factor is the diversity of State laws that regulate the kinds of services PA's may perform. In some States, they have the authority to make medical decisions and prescribe treatment without the immediate supervision of a physician. In others, they are allowed to practice only where a licensed physician is present. Most States restrict the types of drugs a PA can prescribe, and some States prohibit PA's from writing prescriptions altogether. Furthermore, laws regarding PA practice ar under review in some States, where proposals to expand their scope of practice have aroused the opposition of other health providers. Some physicians may be reluctant to hire PA's without knowing what rules will govern their use in coming years.
The now-plentiful supply of physicians affects prospects for PA's. In the early 1960's, the Federal Government took steps to expand the number of graduates from U.S. medical schools. Medical school enrollment has doubled in the past two decades, and the number of physicians in practice has risen sharply. Barring a major surge in demand for medical services, the increasingly abundant supply of physicians is expected to lower patient loads for physicians and possibly decrease the demand for PA's in urban areas.
Some developments could heighten rather than curtail demand for PA's. More doctors are locating in medically underserved areas, which could open up additional employment opportunities for PA's. The growing popularity of health maintenance organizations and other kinds of prepaid health plans is also likely to spur demand. Such plans, which provide complete health care services to members for a set annual charge, employ physician assistants, nurse-midwives, and nurse practitioners in place of some physicians. If HMO's take on a significantly expanded role in health care, demand for PA's would undoubtedly rise.
The aging of the population could also affect employment of PA's. Compared to younger people, the elderly visit physicians more often, spend more money on medicine and drugs, and spend much more time in hospitals. Resolution of the third-party reimbursement issue could lead to greater employment of PA's by nursing homes and home health agencies that serve the elderly.
In 1990, physician assistants starting work in hospitals and medical centers averaged about $27,872, according to a national survey conducted by the University of Texas Medical Branch in Galveston. The middle 50 percent earned between $24,659 and $28,400 a year. Experienced physician assistants averaged about $37,130.
The average starting salary for physician assistants in 1990 was about $28,100. The average salary for all physicians assistants was bout $35,400 during the same time period.
Other health workers who provide direct patient care that requires a similar level of skill and training include nurse practitioners, physical therapists, occupational therapists, and speech and hearing clinicians.
Sources of Additional Information
For more information about the profession, send for the brochure, Physician Assistant, available free from:
American Academy of Physician Assistants, 1117 North 19th St., Suite 300, Arlington, Va. 22209.
Information on individual PA training programs also is available from:
Association of Physician Assistant Programs, 1117 North 19th St., Suite 300, Arlington, Va. 22209.
The Association's publication entitled National Directory of Physician Assistant Programs lists educational programs and describes each program's accreditation status, admission procedures and requirements, and cost. Information on certification requirements is also given. Contact the Association for price and ordering information.
For eligibility requirements and a description of the Physician Assistant National Certifying Examination, write to:
National Commission on Certification of Physician Assistants, Inc., 3384 Peachtree Rd. NE., Suite 560, Atlanta, Ga. 30326.