Physician assistant relationship to physicians

Introduction

Ever since the physician assistant (PA) profession was developed, one of its defining features has been the relationship between PAs and physicians. When physicians created the PA profession, they envisioned PAs practicing medicine with physician delegation and supervision. Throughout the profession’s more than 50-year history, PAs have consistently embraced the concept of team-based health care. PAs believe that the physician–PA team provides the framework of practice to ensure the delivery of high-quality health care.

The relationship was first described by Dr. Eugene Stead of Duke University, who is generally credited with founding the PA profession. In an early monograph describing his vision for the PA’s role, Dr. Stead describes an intention for PAs to be trained in laboratories and clinics to perform an array of procedures, diagnostic tests, and medical therapies. Noting that the physician would direct the activities and would be legally responsible for all acts of the PA, Stead writes that PAs would provide medical care in clinics, hospital settings, patient homes, and outlying communities. Dr. Stead also discusses administrative duties for which PAs would be responsible, including the organization of “medical care units,” which would manage all the aspects and elements of patient care, ranging from technicians and nursing staff to housekeeping and custodial personnel. Although PAs would be trained to recognize certain medical conditions such as heart failure and shock, Stead poses that PAs would not be involved in the clinical diagnosis, decision making, or treatment of medical problems. Nevertheless, as health care delivery has changed and the PA profession has demonstrated its ability to serve patients effectively, that capacity has evolved. Many of the diagnostic and therapeutic responsibilities central to the role and scope of practice of today’s PAs were not part of Stead’s original vision for the profession. Although he may not have anticipated these changes, Stead made this prescient prediction of the value of PAs to physician practice: “They will be capable of extending the arms and the brains of the physician so that he can care for more people.”

The legal, employment, clinical oversight, and collegial dimensions of the relationship between PAs and physicians have always been complex and multifaceted. Over time, those dimensions have been variable given the practice setting, the practice specialty, the employer, and the state in which the PA practiced. Currently, those relationship dimensions are being affected by a variety of forces.

As significant portions of health care delivery have consolidated under the umbrellas of larger health systems, the employment relationship between physicians and PAs has changed. Where PAs were once more commonly employed by solo physicians or groups of private practice physicians in the past, now both PAs and physicians alike are more likely to be employed by health systems. As the decision-making role of health systems regarding team delivery models increases, physicians who may ultimately be teamed with a PA may not hold the final responsibility for hiring decisions.

Another force influencing the PA–physician practice has been the increasing expectations for the efficiency and effectiveness of the team. In addition to patient care responsibilities, PAs and physicians have added responsibilities and demands on their time that affect the function of the team. Additional expectations have been driven by the introduction of the electronic medical record (EMR). Precertification conversations with insurers and other tasks resulting from the patient encounter demand increased clinician attention. Physicians have less time for the roles they have traditionally played in the clinical oversight dimension of team practice: mentoring PA colleagues, responding when called upon to provide guidance with challenging patients, and reviewing charts or discussing cases. Changes have also been seen in the legal dimension. Because physicians may no longer be responsible for hiring decisions and multiple physicians may share the responsibility for the clinical oversight of PAs, the rationale for linking the liability for services delivered by a PA to an individual physician may no longer be logical.

When considering these changes, the American College of Physicians (ACP) expanded on that theme, stating: “Flexibility in federal and state regulation [is encouraged] so that each medical practice determines appropriate clinical roles within the medical team, physician-to-PA ratios, and supervision processes, enabling each clinician to work to the fullest extent of his or her license and expertise.”

Although the PA profession’s commitment to working in team practice is unwavering, there is an increasing recognition that the dimensions of the physician–PA team practice must continue to evolve to reflect the changing practice of medicine. Understanding the proposals for how to further evolve requires one to understand the elements of the PA–physician relationship and how it has changed over time ( Box 2.1 ).

The historic physician assistant–physician relationship

PAs are authorized to practice medicine in all 50 states, the District of Columbia, and all US territories. Although the vast majority of state laws mandate physician supervision or collaboration as a part of PA practice, changes to the definition and degree of supervision have occurred. As the need for increased efficiency and effectiveness of health care delivery has become more and more evident and the capabilities of PAs have been demonstrated, the call for changes to the state law has become more compelling.