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Physician Assistants and Protocols
Physician assistants (PAs) practice medicine with physician supervision. Like physicians, PAs are trained in the medical model in educational programs that are located at medical schools, teaching hospitals, academic medical centers, and in military medical centers. Practicing in physician-directed teams, PAs can be found in all medical and surgical specialties, and in a wide variety of practice, educational and research settings.
Some state laws and/or facility policies direct PAs to practice using detailed clinical protocols. Mandating protocol-based practice is inappropriate for physician assistants. PAs are educated in the medical model and practice with physician supervision. Protocols are useful to PAs to the same extent that they are useful to physicians.
THE PHYSICIAN ASSISTANT EDUCATIONAL MODEL
Applicants to physician assistant programs must complete roughly two years of college courses in basic science and behavioral science as prerequisites to PA training. This is analogous to pre-med studies required of medical students. Preference is usually given to candidates who have prior experience in health care. Most PA students have earned a bachelor's degree and have an average of 48 months of health care experience before they are admitted to a program.
The typical PA educational program is usually 25-27 months in length [1].
Educators of PAs include physicians, PAs, and basic scientists. Physician assistant education is characterized by an intense, yet practical curriculum, with both didactic and clinical components.
The first year of PA education provides a broad grounding in medical principles with a focus on their clinical applicability. This didactic curriculum typically consists of coursework in the basic sciences, including anatomy, physiology, biochemistry, pharmacology, physical diagnosis, pathophysiology, microbiology, clinical laboratory sciences, behavioral sciences, and medical ethics. In the second year, students receive hands-on clinical training through a series of clerkships or rotations in a variety of inpatient and outpatient settings. Rotations include family medicine, internal medicine, obstetrics and gynecology, pediatrics, general surgery, emergency medicine, and psychiatry. Physician assistant students complete on average over 2,000 hours of supervised clinical practice prior to graduation.[2]
TEAM PRACTICE
An unchanging tenet of the PA profession is the commitment to practicing in physician-directed teams. The relationship between physician assistants and physicians begins in PA school where physicians provide much of the instruction in a curriculum following the medical school model.
It is typical for PA students to share classes, facilities, and clinical rotations with medical students. Consequently, physicians and PAs develop a similarity in medical reasoning during their schooling that eventually leads to a homogeneity of thought in the clinical workplace.[3]
The relationship between PAs and physicians is inherent in the definition of the profession and is required by state law. PAs are licensed in all 50 states, the District of Columbia, and Guam. In all of those jurisdictions, the physician assistant is required to have a supervising physician(s) who is responsible for delegating and supervising care provided by the PA.[4]
In 1995 the American Medical Association's House of Delegates adopted "Guidelines for Physician/Physician Assistant Practice." These guidelines describe the roles and relationship of PAs and physicians.[5]
PHYSICIAN ASSISTANTS AND PROTOCOLS
Like physician education, PA education promotes the development of practical skills in clinical problem solving and decision making. Despite this fact, a few state regulatory boards and some facilities occasionally require physician assistants to utilize detailed clinical protocols.
The AAPA recommends that written clinical protocols should not be required as part of state laws or regulations delineating physician assistant scope of practice. Protocols are useful for dealing with very specific clinical entities (e.g., anaphylaxis). However, protocols by their nature are rigid and rapidly outdated. Extensive clinical protocols neither enhance the clinical judgment exercised by physician assistants nor improve the diagnosis and treatment of disease.[6] There is no evidence that requiring extensive clinical protocols at the state regulatory level protects public safety. This requirement may actually hinder care, as it decreases the ability to utilize clinical judgment and individualize treatment for a specific patient.
The AMA guidelines do not recommend protocols in delineating physician/PA practice. Instead, the AMA policy calls for "mutually agreed upon guidelines that are developed by the physician and the physician assistant."[5]
ALTERNATIVES TO PROTOCOLS
The terms "practice description," "job description," "delegation agreement," and "protocol" are often confused or used interchangeably. Sometimes, an employer or regulatory body, in discussing protocols, actually wants a description of how the PA and physician will practice together. For the sake of clarity, we define them as follows:
Practice Description
A broad description of the practice and how the physician and PA will relate within the practice. A practice description might specify the patient population of the practice and types of services, (i.e., family practice, general surgery, ob/gyn); a description of the physician supervision mechanism, such as case conferences, chart review, or availability of the physician on site or by telecommunication; and hospital, nursing home, and call responsibilities in the practice.Job Description
A job description outlines the PA's duties in the practice. It could also describe the relationship of the PA to patients and other personnel. It might include the types of patients the PA will see, hours the PA will work, call responsibilities, and settings in which the PA is expected to provide care.Delegation Agreement
A delegation agreement outlines the patient problems and procedures that the physician delegates the PA to care for or perform. It could be as broad or as specific as the physician/PA team determines is necessary. Ideally it would be reviewed and revised frequently.Protocol
A detailed template for treatment of a specific medical problem. Two examples are Advanced Cardiac Life Support and sub-acute bacterial endocarditis prophylaxis.CONCLUSION
There has been a recent movement to standardize medical practice. The AAPA supports the development of clinical pathways based on evidence based medicine and their appropriate use by physician/PA teams.[7]
The AAPA also supports effective and continuing communication between physicians and PAs who practice together and appropriate delegation and direction from the supervising physician to the PA.
The AAPA opposes state law or facility policy requirements for protocols. There is no evidence that requiring extensive clinical protocols enhances care or protects public safety. This requirement may actually hinder care, as it decreases the ability to utilize clinical judgment and individualize care for a specific patient.
The AAPA recommends that when a PA and physician begin practicing together, they discuss their professional relationship and how they will function as a team. It is important that both parties understand how they will work together and that they evaluate their practice arrangement on an ongoing basis. In most practices, defining everything the PA will be doing through detailed treatment protocols is virtually impossible. It is more practical and promotes better patient care for the PA and physician to work together under a broad job description, practice agreement, or delegation agreement that allows the PA to exercise his or her clinical judgment while consulting the supervising physician as necessary. This team practice model allows for rapid inclusion of new treatment modalities, individualized approach to patient problems, and maximization of the supervising physician's ability to direct patient care in the clinical setting.
REFERENCES
1. Simon AF, Link MS. Sixteenth Annual Report on Physician Assistant Educational Programs in the United States, 1999-2000. Association of Physician Assistant Programs. Alexandria, VA. June 2000.
2, Eleventh Annual Report on Physician Assistant Educational Programs in the United States, 1994-95. Alexandria, VA. Association of Physician Assistant Programs.
3. Estes EH, Jr. "Training doctors for the future: lessons from 25 years of physician assistant education." Clawson DK and Osterweis M., eds., The Roles of Physician Assistants and Nurse Practitioners in Primary Care. Washington, DC. Association of Academic Health Centers, 1993.
4. Physician Assistants: State Laws and Regulations, Seventh Edition. Alexandria, VA. American Academy of Physician Assistants, 1998.
5. American Medical Association. "Guidelines for Physician/Physician Assistant Practice." 1998 Policy Compendium. Chicago, IL.
6. American Academy of Physician Assistants. "Guidelines for State Regulation of PAs." 1997-98 Policy Manual. Alexandria, VA.
7. American Academy of Physician Assistants. "Physician Assistants and Clinical Practice Guidelines." 1997-98 Policy Manual. Alexandria, VA.
Updated: 04/01
Last Revised: 2/1/02
