Physician Assistants in USA

Associate ProfessorDivision of CV Surgery Severance Cardiovascular Hospital Yonsei University College of Medicine, Seoul, Korea

Taek Yeon Lee, MD, PhD

The author has no financial

relationships to disclose

The author has no financial

relationships to disclose

Past – History

Present – Definition, Members, Salary, Education, Association

Future – Growth

Past – History

Present – Definition, Members, Salary, Education, Association

Future – Growth

Memorial Hermann Heart & Vascular Institute-Texas Medical Center

The jurisprudence examination ("JP exam")

The jurisprudence examination ("JP exam")

Texas Administrative CodeTexas Administrative Code

Title 22, Part 9

TEXAS MEDICAL BOARD

BOARD RULES

Chapter 185. Physician Assistants

§§ 185.1 – 185.26

Chapter 184. Surgical Assistants

§§ 184.1 – 184.26

Title 22, Part 9

TEXAS MEDICAL BOARD

BOARD RULES

Chapter 185. Physician Assistants

§§ 185.1 – 185.26

Chapter 184. Surgical Assistants

§§ 184.1 – 184.26

BackgroundBackground Shortage of medically trained personnel Shortage of medically trained personnel

HistoryHistory

17th 17th Feldshers (German:Feldscher, Russian: Фельдшер) are introduced

into Russian armies by Peter the Great in the 17th Century

Feldshers (German:Feldscher, Russian: Фельдшер) are introduced into Russian armies by Peter the Great in the 17th Century

1672-1725

1778 1778 1778, John Wall, to assist medical officers on the USS Constellation 1778, John Wall, to assist medical officers on the USS Constellation

The American Revolutionary War( 1775-1783)

1650-19001650-1900 Officiers de Sante (1803-1892) Officiers de Sante (1803-1892)

The Napoleonic War(1803-1815)

1900- 19601900- 1960 1925 Mts in Kentucky 1940 Alaska, Eskimos and other native Americans Dr. Amos N. Johnson employs

Henry B. Treadwell in Garland, NC 1942 Dr. EA Stead - fast track to educate physicians at Emory University

for military service during WW II

1925 Mts in Kentucky 1940 Alaska, Eskimos and other native Americans Dr. Amos N. Johnson employs

Henry B. Treadwell in Garland, NC 1942 Dr. EA Stead - fast track to educate physicians at Emory University

for military service during WW II

1908-1975

1908-2005

Eugene A. Stead, Jr.MD(1908-2005)

Eugene A. Stead, Jr.MD(1908-2005)

Late 1950s masters program for nurse clinicians with Thelma Ingles, a nurse

educator, had established at Duke

1965 first formal educational program for PA at Duke

National PA Day is celebrated each year on his birthday - October 6th.

Late 1950s masters program for nurse clinicians with Thelma Ingles, a nurse

educator, had established at Duke

1965 first formal educational program for PA at Duke

National PA Day is celebrated each year on his birthday - October 6th.

1966-19721966-1972 1966  PA concept on “Look”

"More than a nurse, less than a doctor“

1966  PA concept on “Look”

"More than a nurse, less than a doctor“

1966 - 19721966 - 1972

1967 Dr. John Webster Kirklin, first formal program for SA (UAB) First Class of three PAs graduate from Duke

VH. Germino, KF. Ferrell and RJ. Scheele

1968 Duke University – first of 4 national conferences American Association of Physician's Assistants (AAPA)

1967 Dr. John Webster Kirklin, first formal program for SA (UAB) First Class of three PAs graduate from Duke

VH. Germino, KF. Ferrell and RJ. Scheele

1968 Duke University – first of 4 national conferences American Association of Physician's Assistants (AAPA)

1917-2004

1966-19721966-1972 1971 American Association of Physician's Assistants (AAPA) - first official

journal

1971 American Association of Physician's Assistants (AAPA) - first official

journal

1966-19721966-1972 1972 National Board of Medical Examiners ( NBME) begins the process

of developing a certification exam.

1972 National Board of Medical Examiners ( NBME) begins the process

of developing a certification exam.

19741974

APAP Association of Physicians’ Assistant Programs

APAP Association of Physicians’ Assistant Programs

19751975

The National Commission on Certification of Physician's Assistants (NCCPA)

Registered every 2 y Recertified every 6 y

The National Commission on Certification of Physician's Assistants (NCCPA)

Registered every 2 y Recertified every 6 y

Certifying ExamCertifying Exam

1983 PANCE NCCPA's Physician Assistant National Certifying Examination

(PANCE) was redesigned to include three components:

1 .a general knowledge/core component

2. extended core component in surgery or primary care

3. a clinical skills problems component (CSPs).

1985 PANRE

1983 PANCE NCCPA's Physician Assistant National Certifying Examination

(PANCE) was redesigned to include three components:

1 .a general knowledge/core component

2. extended core component in surgery or primary care

3. a clinical skills problems component (CSPs).

1985 PANRE

19881988

19991999 CB-PANCE CB-PANCE

20002000 CB – PANRE CB – PANRE

20032003

Texas becomes 41st State to authorize controlled substance prescribing for PAs.

Texas becomes 41st State to authorize controlled substance prescribing for PAs.

Other CountriesOther Countries

1992 The Canadian National Forces begin training

and using PAs.

2002 Canadian, Dutch and British

1992 The Canadian National Forces begin training

and using PAs.

2002 Canadian, Dutch and British

ChinaChina

Barefoot doctor 赤脚医生 1968-1981

Barefoot doctor 赤脚医生 1968-1981

PresentPresent

DefinitionDefinition

PA / SA LPNs - Licensed Practical Nurses PA-C / SA-C CST - Certified Surgical Technologist CFA - Certified First Assistants CRNFAs - Certified Registered Nurse First

Assistants

PA / SA LPNs - Licensed Practical Nurses PA-C / SA-C CST - Certified Surgical Technologist CFA - Certified First Assistants CRNFAs - Certified Registered Nurse First

Assistants

PA NomenclaturePA Nomenclature Early years : ’s – physician’s assistant physician’s associate – Duke Univ.

new health practitioners, clinical or health associates, physician extenders, mid-level practitioners, and non-physician health care providers.

In the 1980's, AAPA refer to themselves as PA (physician assistants)

Physician Assistant is the current term used to describe the profession.

Early years : ’s – physician’s assistant physician’s associate – Duke Univ.

new health practitioners, clinical or health associates, physician extenders, mid-level practitioners, and non-physician health care providers.

In the 1980's, AAPA refer to themselves as PA (physician assistants)

Physician Assistant is the current term used to describe the profession.

Applying to PA ProgramsApplying to PA Programs

health care experience Bachelor’s degrees, Master’s degrees

degree college-level courses include basic sciences; math; English/writing;

some specialized science courses, such as anatomy/physiology, microbiology, physics; computer sciences; and medical terminology.

health care experience Bachelor’s degrees, Master’s degrees

degree college-level courses include basic sciences; math; English/writing;

some specialized science courses, such as anatomy/physiology, microbiology, physics; computer sciences; and medical terminology.

EducationEducation

149 education programs for PA

medical schools and centers, hospitals, colleges and universities

149 education programs for PA

medical schools and centers, hospitals, colleges and universities

PA EducationPA Education

similar to that for medical students, although shorter in duration

(medical school education averages 155w; PA 111w)

24 - 27 m part-time education ½ classroom studies, ½ clinical rotations.

similar to that for medical students, although shorter in duration

(medical school education averages 155w; PA 111w)

24 - 27 m part-time education ½ classroom studies, ½ clinical rotations.

LicensureLicensure 1. graduates of accredited PA education programs 2. pass the PANCE (Physician Assistant National Certifying

Examination)

To remain certified 100 hours of continuing medical education every 2 years must pass a recertification examination every 6 years

1. graduates of accredited PA education programs 2. pass the PANCE (Physician Assistant National Certifying

Examination)

To remain certified 100 hours of continuing medical education every 2 years must pass a recertification examination every 6 years

MembersMembers

By AAPA, US Department of Labor's Bureau of Labor Statistics 2008-2009

1993 - 26,400 PAs

1997 - 28,500 PAs

2002 - 45,000 PAs

2006 - 86,000 PAs

CRNFAs 1,621 / SA 10,000 / CFAs 1,425 / SA-Cs 948 / CSAs 805

By AAPA, US Department of Labor's Bureau of Labor Statistics 2008-2009

1993 - 26,400 PAs

1997 - 28,500 PAs

2002 - 45,000 PAs

2006 - 86,000 PAs

CRNFAs 1,621 / SA 10,000 / CFAs 1,425 / SA-Cs 948 / CSAs 805

ScopeScope

RULE §185.10 (PA)

(1) obtaining patient histories and performing physical examinations;   (2) ordering and/or performing diagnostic and therapeutic procedures;   (3) formulating a working diagnosis;   (4) developing and implementing a treatment plan;   (5) monitoring the effectiveness of therapeutic interventions;   (6) assisting at surgery;   (7) offering counseling and education to meet patient needs;   (8) requesting, receiving, and signing for the receipt of pharmaceutical sample prescription

medications and distributing the samples to patients in a specific practice setting where the physician assistant is authorized to prescribe pharmaceutical medications and sign prescription drug orders at a site, as provided by the Medical Practice Act, Chapter 157, and its subsequent amendments, or as otherwise authorized by this Act or board rule;

  (9) the signing or completion of a prescription as provided by the Medical Practice Act, Chapter 157; and

  (10) making appropriate referrals.

RULE §185.10 (PA)

(1) obtaining patient histories and performing physical examinations;   (2) ordering and/or performing diagnostic and therapeutic procedures;   (3) formulating a working diagnosis;   (4) developing and implementing a treatment plan;   (5) monitoring the effectiveness of therapeutic interventions;   (6) assisting at surgery;   (7) offering counseling and education to meet patient needs;   (8) requesting, receiving, and signing for the receipt of pharmaceutical sample prescription

medications and distributing the samples to patients in a specific practice setting where the physician assistant is authorized to prescribe pharmaceutical medications and sign prescription drug orders at a site, as provided by the Medical Practice Act, Chapter 157, and its subsequent amendments, or as otherwise authorized by this Act or board rule;

  (9) the signing or completion of a prescription as provided by the Medical Practice Act, Chapter 157; and

  (10) making appropriate referrals.

ScopeScope RULE §184.12 (SA)

These generally include the following tasks: aid in maintaining adequate exposure in the operating field, cutting suture materials, clamping and ligating bleeding vessels, and, in selected instances, actually performing designated parts of a procedure...

The practice of surgical assisting is limited to surgical assisting performed under the direct supervision of a physician who delegates the acts. A surgical assistant may practice in any place authorized by a delegating licensed physician, including, but not limited to a clinic, hospital, ambulatory surgical center, or other institutional setting.

RULE §184.12 (SA)

These generally include the following tasks: aid in maintaining adequate exposure in the operating field, cutting suture materials, clamping and ligating bleeding vessels, and, in selected instances, actually performing designated parts of a procedure...

The practice of surgical assisting is limited to surgical assisting performed under the direct supervision of a physician who delegates the acts. A surgical assistant may practice in any place authorized by a delegating licensed physician, including, but not limited to a clinic, hospital, ambulatory surgical center, or other institutional setting.

ScopeScope American College of Surgeons (ACS) American Medical Association (AMA)

(e) Ideally, the first assistant to the surgeon at the operating table should be a qualified surgeon or resident in an education program that is accredited by the Accreditation Council for Graduate Medical Education (ACGME) and/or the American Osteopathic Association (AOA).

The AMA recognizes that attainment of this ideal in all surgical care settings may not be practicable. In some circumstances it is necessary to utilize appropriately trained and credentialed unlicensed physicians and non-physicians to serve as first assistants to qualified surgeons (emphasis added).

American College of Surgeons (ACS) American Medical Association (AMA)

(e) Ideally, the first assistant to the surgeon at the operating table should be a qualified surgeon or resident in an education program that is accredited by the Accreditation Council for Graduate Medical Education (ACGME) and/or the American Osteopathic Association (AOA).

The AMA recognizes that attainment of this ideal in all surgical care settings may not be practicable. In some circumstances it is necessary to utilize appropriately trained and credentialed unlicensed physicians and non-physicians to serve as first assistants to qualified surgeons (emphasis added).

ScopeScope

Physician / Surgeon’s scope Direct supervision

In selected ….. May practice …. Ideally …../ Practically ….. In some circumstances, …..

Physician / Surgeon’s scope Direct supervision

In selected ….. May practice …. Ideally …../ Practically ….. In some circumstances, …..

SupervisionSupervision (a) Supervision shall be continuous, and shall require that the

delegating physician be physically present and immediately available in the operating room to personally respond to any emergency until the patient is released from the operating room and care has been transferred to another physician. Telecommunication is insufficient for supervision purposes. (§184.13. Supervision)

(a) Supervision shall be continuous, but shall not be construed as necessarily requiring the constant physical presence of the supervising physician at a place where physician assistant services are performed while the services are performed. Telecommunication shall always be available. (§185.14. Supervision)

(a) Supervision shall be continuous, and shall require that the delegating physician be physically present and immediately available in the operating room to personally respond to any emergency until the patient is released from the operating room and care has been transferred to another physician. Telecommunication is insufficient for supervision purposes. (§184.13. Supervision)

(a) Supervision shall be continuous, but shall not be construed as necessarily requiring the constant physical presence of the supervising physician at a place where physician assistant services are performed while the services are performed. Telecommunication shall always be available. (§185.14. Supervision)

SupervisionSupervision

PA (§185.14. Supervision) not constant physical presence

Telecommunication be available

SA (§184.13. Supervision) continuous, physically present and immediately available in the

operating room

Telecommunication is insufficient

PA (§185.14. Supervision) not constant physical presence

Telecommunication be available

SA (§184.13. Supervision) continuous, physically present and immediately available in the

operating room

Telecommunication is insufficient

EarningEarning May 2008

Median $81,230 ( $68,210 - $97,070 ) The lowest 10 percent ≤ $51,360 The highest 10 percent ≥ $110,240

http://www.bls.gov/oco/ocos081.htm

Median $85,710 ; median income for first-year $74,470 Income varies by specialty, practice setting, geographical location,

and years of experience. By AAPA 2008 Census Report

May 2008

Median $81,230 ( $68,210 - $97,070 ) The lowest 10 percent ≤ $51,360 The highest 10 percent ≥ $110,240

http://www.bls.gov/oco/ocos081.htm

Median $85,710 ; median income for first-year $74,470 Income varies by specialty, practice setting, geographical location,

and years of experience. By AAPA 2008 Census Report

$ 85,710

* 1209.00 ( 2010-06-01)

₩ 103,623,390

$ 85,710

* 1209.00 ( 2010-06-01)

₩ 103,623,390

PAs practicePAs practice 2008

family and general medicine (25.9 %) general surgery and surgical subspecialties

(25.1 %) general internal medicine and its subspecialties (15.6 percent) emergency medicine (10.5 percent) pediatrics and pediatric subspecialties (4.3 percent) dermatology (3.6 percent) occupational medicine (2.3 percent) obstetrics and gynecology (2.3 percent) and other areas of medicine.

2008

family and general medicine (25.9 %) general surgery and surgical subspecialties

(25.1 %) general internal medicine and its subspecialties (15.6 percent) emergency medicine (10.5 percent) pediatrics and pediatric subspecialties (4.3 percent) dermatology (3.6 percent) occupational medicine (2.3 percent) obstetrics and gynecology (2.3 percent) and other areas of medicine.

FutureFuture

Who Knows?Who Knows?

Only God Knows. Only God Knows.

1981 HMO ; 50% of cost, 79% of care PAs are cost-effective and productive members of the healthcare

team

Employment of PA is expected to grow by 39 % from 2008 to 2018

1981 HMO ; 50% of cost, 79% of care PAs are cost-effective and productive members of the healthcare

team

Employment of PA is expected to grow by 39 % from 2008 to 2018

Thank You!!Thank You!!

2011 ABSA Certification Examination for Surgical Assistants

2011 ABSA Certification Examination for Surgical Assistants

1.    Hold a medical degree from a  medical school listed in the International Medical Education Directory (IMED), documenting English proficiency.

          OR

2.   ABSA approved formal surgical assistant training program. And

3.   ALL the following college-level courses,          1 year, English Composition or Technical Writing, Human Anatomy & Physiology         1 semester, General Biology, Microbiology, Pathophysiology, Pharmacology, Verbal Communication course

or equivalent, College Algebra

1.    Hold a medical degree from a  medical school listed in the International Medical Education Directory (IMED), documenting English proficiency.

          OR

2.   ABSA approved formal surgical assistant training program. And

3.   ALL the following college-level courses,          1 year, English Composition or Technical Writing, Human Anatomy & Physiology         1 semester, General Biology, Microbiology, Pathophysiology, Pharmacology, Verbal Communication course

or equivalent, College Algebra

Controlled SubstancesControlled Substances Schedule I - high potential for abuse. Not accepted medical use Cannabis. Heroin nicomorphine (Vilan), dextromoramide (Palfium), ketobemidone (Ketalgin),

dihydromorphine (Paramorfan), piritramide (Dipidolor), diacetyldihydromorphine (Paralaudin), dipipanone (Wellconal), phenadoxone (Heptalgin) and many others.

Schedule II - accepted medical use with severe restrictions. Fentanyl Cocaine (used as a topical anesthetic),Methylphenidate (Ritalin and Concerta) & Opium, Methadone

Schedule III - a potential for abuse less than the drugs in I and II. Anabolic steroids (including prohormones such as androstenedione); Ketamine, Hydrocodone / codeine, when compounded with an NSAID (e.g. Vicoprofen, when

compounded with ibuprofen) or with acetaminophen (paracetamol) (e.g. Vicodin)

Schedule IV - low potential for abuse relative to the drugs in III. BenzodiazepinesLong-acting barbiturates such as phenobarbital;

Schedule V - low potential for abuse relative to the drugs in IV. Cough suppressants containing small amounts of codeine (e.g., promethazine+codeine); Preparations containing small amounts of opium or diphenoxylate (used to treat diarrhea); Pyrovalerone

Schedule I - high potential for abuse. Not accepted medical use Cannabis. Heroin nicomorphine (Vilan), dextromoramide (Palfium), ketobemidone (Ketalgin),

dihydromorphine (Paramorfan), piritramide (Dipidolor), diacetyldihydromorphine (Paralaudin), dipipanone (Wellconal), phenadoxone (Heptalgin) and many others.

Schedule II - accepted medical use with severe restrictions. Fentanyl Cocaine (used as a topical anesthetic),Methylphenidate (Ritalin and Concerta) & Opium, Methadone

Schedule III - a potential for abuse less than the drugs in I and II. Anabolic steroids (including prohormones such as androstenedione); Ketamine, Hydrocodone / codeine, when compounded with an NSAID (e.g. Vicoprofen, when

compounded with ibuprofen) or with acetaminophen (paracetamol) (e.g. Vicodin)

Schedule IV - low potential for abuse relative to the drugs in III. BenzodiazepinesLong-acting barbiturates such as phenobarbital;

Schedule V - low potential for abuse relative to the drugs in IV. Cough suppressants containing small amounts of codeine (e.g., promethazine+codeine); Preparations containing small amounts of opium or diphenoxylate (used to treat diarrhea); Pyrovalerone

19611961 1961 Charles L. Hudson,MD “Expansion of Medical Professional Services

with Nonprofessional Personnel” in the June 10, 1961 in JAMA.

1961 Charles L. Hudson,MD “Expansion of Medical Professional Services

with Nonprofessional Personnel” in the June 10, 1961 in JAMA.

19641964 1964   Dr. Richard A. Smith - the MEDEX (Med-icine Ex-tension) model

1964   Dr. Richard A. Smith - the MEDEX (Med-icine Ex-tension) model

1932-