A physician assistant (US) or physician associate (UK) is a healthcare professional who provides healthcare within the medical model as part of a team with physicians and other providers, holding a qualification that can be gained in less time than a medical degree. In the United States, physician assistants are nationally certified and state licensed to practice medicine under the supervision of a physician.
PAs are concerned with preventing and treating human illness and injury by providing a broad range of health care services under the supervision of a physician. Their scope of practice can vary according to jurisdiction and healthcare setting, some will require a license. Accordingly, their work may include conducting physical exams, ordering and interpreting tests, diagnosing illnesses, developing treatment plans, performing procedures, prescribing medications, advising on preventive health care, and assisting in surgery.
The occupational title originated in the United States in the 1960s; similar occupations outside the US include clinical officers in part of Africa and feldshers in countries of the former Soviet Union.
Overview
Physician assistants or physician associates (PAs) typically obtain medical histories, perform examinations and procedures, order treatments, diagnose diseases, prescribe medication, order and interpret diagnostic tests, refer patients to specialists as required, and first or second-assist in surgery. They work in hospitals, clinics and other types of health facilities, or in academic administration, and exercise autonomy in medical decision making. PAs 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 shorter in duration, includes all systems of the human body. Renewal of licensure is necessary every few years, varying by jurisdiction. Physician assistants may also complete 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.
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History
The PA profession was first proposed in the United States when Charles Hudson recommended to the American Medical Association (AMA), in 1961, the "creation of two new groups of assistants to doctors from nonmedical and nonnursing personnel." 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 former U.S. Navy Hospital Corpsmen. 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. 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.
Beginning in January 1971, 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)
Although the PA profession has historically consisted mostly of men, women now constitute over 60% of physician assistants in the United States.
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; assistant medical officers in Malaysia; assistant doctors in China; Health extension officers in Papua New Guinea and feldsher in countries of the former Soviet Union.
Canada
As of October 2015, there are approximately 400 PAs working in healthcare settings in Canada. The first formally trained PAs graduated in 1984 from the Canadian Forces Medical Services School at Borden, Ontario. The Canadian Medical Association (CMA) recognized the PA as a health professional in 2003.
The first civilian PA education programs were launched in 2008 at the University of Manitoba and McMaster University. 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".
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 USA in the 1960s. In 2012, the profession voted to change the name of 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 USA for 40 NHS trusts in September 2015.
Scope of practice
PAs are trained under the medical model, similarly to doctors, to deliver high-quality medical care in both primary and secondary care settings. 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 and taking medical histories.
They work under the direct supervision of a doctor. Due to the infancy of the profession, there is currently limited progression to senior posts, but there has been an emphasis on employers to develop dedicated study leave and training times to help develop their skills, this is often paired with junior doctor training. The current avenues which PAs can develop their skills are through research, teaching, training to become first assistants in surgery and running outpatient clinics and post-surgical follow ups. Tasks they perform include medical history taking, interpreting ECG and venipuncture/blood draws, among others.
Regulation and regulatory body
The title of physician associate is not a protected medical profession. Hence many PAs who have been trained in pharmacology and IRMER (ability to request radiology imaging- X-Rays) are NOT able to prescribe or request imaging, though it has been noted that there may be loopholes in this. However, the UK Association of Physician Associates has re-affirmed their stance that this is against the law and the individual is liable to legal prosecution if found prescribing drugs or imaging. At present there is no regulatory body for PAs, such as the General Medical Council (GMC) for doctors. The only current method of regulation within the professional body is membership of the Managed Voluntary Register (MVR) for Physician Associates. This database, run by PAs for PAs, aims to identify all qualified PAs who are able to practise in the United Kingdom. It is designed to regulate the profession to maintain high standards and to prevent non-Physician Associate qualified individuals being employed as a Physician Associate in the UK. Due to this problem it is mandatory to be a verified member of this register for employers to consider an application to a job posting.
Professional
Physician associates in the United Kingdom are required to re-certify every 5-6 years 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.
Training
PA training in the UK is through a 2-year MSc or Postgraduate Diploma in Physician Associate Studies. There are 14 universities currently offering the programme.
o St George's, University of London o Aberdeen University o University of Birmingham o Plymouth University o University of Worcester o University of Wolverhampton o University of East Anglia o University of Leeds o Sheffield Hallam University o Canterbury Christ Church University o Anglia Ruskin University o University of Reading o Royal College of Surgeons o Hull York Medical School
Aberdeen requires a science- based degree minimum 2:1 grade achieved and St George's require a science-based degree with a minimum 2:2 grade achieved. This includes Sport Science, Biology, Geology, Psychology and Biomedical based degrees. Applicants should preferably have experience in the health care industry, such as a HCA, auxiliary nursing. Applications from other professionals such as Nurses, radiographers and paramedics will also be considered.
Re-certification
The six-year certification maintenance cycle (PAs began transitioning to a new ten-year certification maintenance cycle in 2014) is divided into three two-year periods (five two-year periods for those now on the ten-year cycle). During every two-year period, PA-C designees must earn and log a minimum of 100 credits of CME and submit a certification maintenance fee to NCCPA by 11:59 p.m. PT, December 31 of their certification expiration year.
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. It was not until 1970 that the AMA passed a resolution to develop educational guidelines and certification procedures for PAs. The Duke University Medical Center Archives has established the Physician Assistant History Center, dedicated to the study, preservation, and presentation of the history of the PA profession.
Education and certification
As of August 2015, there were 222 accredited or developing PA programs in the United States, represented by the Physician Assistant Education Association (PAEA). 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. 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 although unlike medical school which lasts four years plus a specialty-specific residency, PA training is usually 2 to 3 years of full-time study, completed during their post-graduate studies, for a total of 6-7 years of science-based postsecondary education. 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. 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. Despite this, there are residency programs in certain specialties for PAs who choose to continue formal education in such a format.
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. The Montefiore Medical Center Postgraduate Surgical Physician Assistant Program was established in 1971 as the first clinical postgraduate PA program to be recognized. Currently, there are known to be 49 programs in various specialties such as Neurology, Trauma/Critical Care and Oncology. The Association of Postgraduate Physician Assistant Programs was formed in 1988 as an instrument in the establishment of educational standards for postgraduate PA programs and currently includes 50 member programs.
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; The "A" indicates completion of the Army Flight Surgeon Course. 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. 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)
"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.
Scope of practice
Physician assistants have their own licenses with distinct scope of practice. Each of the 50 states has different laws regarding the prescription of medications by mid-level practitioners (which include PAs) and the licensing authority granted to each category within that particular State through the Drug Enforcement Administration (DEA). PAs in Florida, Kentucky, Puerto Rico and the U.S. Virgin Islands are not allowed to prescribe any controlled substances. 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.
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 supervisor. The physician supervisor must also be licensed in the state in which the PA is working, although he or she may physically be located elsewhere. Physician supervision can be in person, by telecommunication systems or by other reliable means (for example, availability for consultation).
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 2000 PAs.
According to the AAPA, there were an estimated 68,124 PAs in clinical practice as of January 2008.
In the 2008 AAPA census, 56 percent of responding PAs worked in physicians' offices or clinics and 24 percent were employed by hospitals. The remainder were employed in public health clinics, nursing homes, schools, prisons, home health care agencies, and the United States Department of Veterans Affairs Fifteen percent of responding PAs work in counties classified as non-metropolitan by Economic Research Service of the United States Department of Agriculture; approximately 17% of the US population resides in these counties.
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..." 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.
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.
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%. In 2010, CNN Money rated the Physician Assistant Career as the number two Best Job In America. In 2012, Forbes rated the Physician Assistant Degree as the number one master's degree for jobs. In 2015, Glassdoor rated Physician Assistant as the Number One Best Job In America. According to the 2014 National Salary Survey of PAs, the mean total income for physician assistants working full-time was $112,344. Physician assistants in emergency medicine, dermatology, and surgical subspecialties may earn $100,000 to $200,000 per year.
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 authorized members of the state department. 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.
U.S. Army PAs typically serve as Medical Specialist Corps officers within Army combat or combat support battalions located in the continental United States, Alaska, Hawaii, and overseas. 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.
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. 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.
The Marine Physician Assistant (MPA) is a U.S. Merchant Mariner Staff Officer. A Certificate of Registry is granted through The United States Coast Guard National Maritime Center (NMC) located in Martinsburg, West Virginia. Formal training programs for Marine Physician Assistants began in September, 1966 at the Public Service Health Hospital located in Staten Island, N.Y.
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