FORUM physician assistants
Physician Assistants in Emergency Medicine Physician assistants (PAs) specially trained in emergency medicine can be used effectively to work with emergency medicine physicians to provide efficient and expedient high-quality patient care. The concept of using PAs in the emergency department is reviewed, and items of concern to professionals who are reluctant to use PAs are discussed. Financial issues and malpractice risk are examined, and our experience with patient perceptions is summarized. The PA program at Beth Israel Medical Center is used as a case study to demonstrate the use and integration of the PA within the division of emergency services. Although a well-trained emergency physician is the gold standard for quality patient care, cost-effective quality care for certain patient complaints can be rendered acceptably by others. [Sturmann KM, Ehrenberg K, Salzberg MR: Physician assistants in emergency medicine. Ann Emerg Med March 1990;19:304-308.]
INTRODUCTION Physician assistants (PAs) are midlevel health professionals qualified by academic and clinical training to perform tasks traditionally reserved for the physician. They are trained to take histories and perform physical examinations, to order and interpret diagnostic tests, to perform procedures such as suturing and casting, and to diagnose and manage many common health problems. PAs are dependent health professionals who work under the supervision of a licensed physician and often are called "physician extenders" because of their ability to perform delegated responsibilities in the diagnostic and therapeutic management of patients. Currently, there are 50 PA programs nationwide, all accredited by the Joint Review Committee on Educational Programs for Physician Assistants under the auspices of the American Medical Association. Depending on academic prerequisites, the curriculum design and length of study vary from two to four years. In addition to the primary-care PA programs, there are graduate and postgraduate programs in specialty areas such as emergency medicine, anesthesiology, pediatrics, and surgery. The graduate receives a PA certificate, which allows him to be registered and sit for the national certification examination, which was developed by the National Board of Medical Examiners and is administered by the National Commission on Certification of Physician Assistants. A certified PA must pass the examination, complete 100 hours of continuing medical education credits every two years, and take a mandatory recertification examination every six years. PAs are the only allied health professions who have a self-regulatory system with a periodic mandatory recertification examination. All states except New Jersey have legislation governing the use of PAs. Requirements pertaining to registration and certification, as well as prescriptive privileges, vary according to state regulations. The graduate PA is trained in primary care, and specialization is accomplished by either postgraduate studies or on-the-job training. The training and certification process, which emphasizes the recognition of limitations and the need for consultation, establishes the PA as a midlevel health care worker well suited to become an integral part of the emergency department medical team.
19:3 March 1990
Annals of Emergency Medicine
Kai M Sturmann, MD Kathleen Ehrenberg, PA-C Marc R Salzberg, MD, FACEP New York, New York From Emergency Services, Beth Israel Medical Center, New York, New York. Received for publication February 6, 1989. Revision received October 18, 1989. Accepted for publication November 28, 1989. Address for reprints: Kai Sturmann, MD, Emergency Services, Beth Israel Medical Center, First Avenue at 16th Street, New York, New York.
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PHYSICIAN ASSISTANTS Sturmann, Ehrenberg & Salzberg
PHYSICIAN SUPPLY A N D D E M A N D FOR EMERGENCY CARE There is a current shortage of approximately 14,000 emergency physicians. 1 At this time, approximately 8,000 emergency physicians are certified by the American Board of Emergency Medicine. The American College of Emergency Physicians maintains that all physicians working in EDs should be board certified in emergency medicine, z While this goal is echoed by hospital administrators, ED directors, and governm e n t regulators, the fact remains that only 36% of physicians currently practicing in hospital EDs are board certified. 3 With existing residency training positions allowing for approximately 450 graduates a year, attrition needs for retirement, death, and disability are not being met. Clearly, the realization of EDs staffed t o t a l l y by e m e r g e n c y m e d i c i n e board-certified physicians is many years away.
providing patient care, it is likely that decreasing government funding and tighter control over residents' w o r k i n g h o u r s will decrease the availability of such residents. 4 Also, because of the additional time required for teaching and supervision, resident physicians m a y not add a positive net effect to patient flow. In our experience, once PAs have been trained and are oriented to the d e p a r t m e n t , t h e y require significantly less supervision than do residents from rotating specialties. The use of patient care protocols without necessary m o n t h l y orientations results in a more predictable quality of care. Quality assurance is easier to manage when dealing with full-time health care providers. While some residents are extremely capable, efficient, and hard working, others see their rotation through the ED as an undesirable obligation. The PA may be a better alternative than the use of off-service residents.
PATIENT PERCEPTIONS THE PHYSICIAN ASSISTANT AS A N ALTERNATIVE TO TRADITIONAL COVERAGE H o s p i t a l EDs u n a b l e to a t t r a c t qualified full-time attending physicians frequently revert to " m o o n lighting physicians" to temporarily fill schedule vacancies. A l t h o u g h many of these physicians are highly capable practitioners, m a n y are ill equipped to deal with the variety of pathologies presenting to a full-service ED. In this situation, the PA trained in emergency medicine and closely s u p e r v i s e d by a certified emergency physician is able to render superior patient care at a lower cost. Because moonlighting physicians may only work a few shifts a month in the ED, full-time PAs constitute a far more stable force. As such, the PA may become more familiar with the physical layout as well as with the functional aspects of the department. One PA working within well-defined protocols and under the guidance of a full-time attending will be easier to s u p e r v i s e t h a n several moonlighting physicians, resulting in better quality assurance. Scheduling will be simplified because fewer individuals need to be considered when making up a schedule. Even for t h o s e EDs f o r t u n a t e enough to have rotating residents 132/305
Patient perception of the PA is overwhelmingly positive. Time-motion studies have shown that when a PA is used, waiting periods are reduced and patients receive greater attention from various health professionals. 5 In our own institution, unsolicited letters from patients concerning the care rendered by PAs are ten times more likely to be favorable than unfavorable. In a 1981 National Survey of Physician Assistants, 95.7% of the 4,822 PAs surveyed rated acceptance by patients as either good or excellent. Indeed, it was perceived that patient acceptance of PAs was significantly better than the acceptance of PAs by physicians and nurses. 6 A favorable response by the patient population is one of the reasons that a PA program is considered a good risk management tool.
COST ANALYSIS The Graduate Medical Education National Advisory Committee, after a study involving general practice outpatient visits, concluded that PAs could be substituted for physicians at a ratio of 0.5:1 to 0.75:1 when the number of patients was used as the output measure. 7 This number is at best a rough approximation because the study did not consider PAs in an ED. In addition, productivity meaAnnals of Emergency Medicine
sured in terms of patient visits will vary greatly depending on whether a PA or an attending physician was assigned to work a fast track, an acute care, or a general treatment area. The average annual salary for a certified PA in the Northeast is about 40% of the average salary for a boardcertified attending emergency physician. 8 It is clear that using even a low PA-to-physician productivity ratio of 0.5:1, PAs still provide high-quality medical care at a lower cost. The majority of third-party payers, such as major insurance companies and Medicaid and Medicare, reimburse institutions or practice groups at t h e s a m e r a t e r e g a r d l e s s of whether the patient is seen only by an attending physician or by the PA who is supervised by the attending. 9 Reduction of ED waiting time significantly reduces malpractice liability and increases patient volume, which will lead to increased financial reimbursement to the institution. Ultimately, these savings could be passed on to the health care consumer by reducing patient charges.
QUALITY OF CARE--RISK MANAGEMENT A N D MALPRACTICE CONCERNS Central to any discussion of alternatives in health care delivery is the issue of quality of care. Several indepth studies have concluded that the quality of medical services provided by PAs is generally equal to the quality of services provided by physicians.lO, ll Chart documentation by PAs is remarkably detailed and complete, e s p e c i a l l y c o m p a r e d w i t h house officer charting. This demonstrates how the consistency offered by an ED-based PA impacts on quality of care. Poor d o c u m e n t a t i o n is also more easily addressed with the PA because of the more permanent nature of the position. On a larger scale, the quality of patient care can be reviewed by looking at malpractice claims involving PAs. The limited data available, however, apply to all PAs in clinical practice - not just those working in an ED. The Assistant General Counsel to the American Medical Association, addressing the National Conference of the American Academy of Physician Assistants, remarked that, "after looking at the ways in which PAs perform their services, I feel PAs probably hold the potential for being 19:3 March 1990
Subject: Physician Assistant Treat and Release Policy I Poficy: Patients presenting in the emergency department with the following complaints may be evaluated and referred by the examining physician assistant without being seen by an attending physician: All venereal disease in men; the following venereal disease in women: monilia, trichomonas, scabies, and lice Urinary tract infection Minor laceration Follow-up on wound check, cast check, suture removal Upper respiratory infections Otitis media and otitis externa Cerumen removal Foreign body removal (uncomplicated) Uncomplicated hepatitis or exposure to hepatitis Low back pain that is chronic and not associated with neurological findings Minor burns Skin rashes Minor gynecological disorders, such as vaginitis and insignificant abnormalities of menstruation Incision and drainage of simple abscesses Conjunctivitis Hemorrhoids Animal bites Chronic peripheral vascular disease Medical clearance for psychiatric patients Normal pregnancy without accompanying medical problems
Referral to specialty service (eg detoxification, abortion, social service) Con sti pation Prescription refills Fatigue or dizziness without associated findings Minor psychiatric disorders Minor symptoms of alcohol or drug withdrawal Allergic reactions not accompanied by shortness of breath, wheezing, or hypotension Bleeding from any orifice that is minor (determined after objective examination) Headache not associated with acute neurological findings Minor febrile illnesses Hypertension that is asymptomatic and accompanied by a diastolic blood pressure of less than 110 mm Hg Shortness of breath not accompanied by cyanosis, upper airway obstruction, or acute respiratory distress Chest pain that is not typical of ischemic chest pain; is not accompanied by syncope, shortness of breath, arrhythmias; and for which an etiology is clear (eg, costochondritis)
Subject: Physician Assistant Treat and Release Policy II Policy: All patients presenting in the emergency department with the following complaints must be evaluated by the attending physician on duty before discharge by the physician assistant: Abdominal pain: all patients Alcohol or drug withdrawal: associated with confusion, hallucinations, fever, seizures, or delirium Allergic reaction: accompanied by shortness of breath, wheezing, or hypotension Arrhythmias: of recent onset or associated with unstable hemodynamics Bleeding: significant bleeding from any orifice confirmed by objective examination Burns: any third-degree burns; second-degree burns of more than 10% of the total body surface; burns of the eyes, ears, face, hands, feet, and perineum; electrical injury; inhalation injury
one of the best malpractice tools available at the present time. 'q2 Because of the variation in reporting claims, disposition of claims, and lack of a central database, it is difficult to determine the exact incidence of medical malpractice claims involving PAs. A US Government Accounting Office medical malpractice study showed that the frequency of 19:3 March 1990
Chest pain: typical of ischemic chest pain or accompanied by syncope, shortness of breath, or arrhythmias Coma or acute change in mental status: all patients Drug overdose: all patients Head trauma: accompanied by loss of consciousness, neurological findings, or other associated injuries Headache: associated with acute neurological findings Heat injury: hypothermia (temperature less than 35 C) or hyperthermia (temperature more than 40.5 C) Hypertension: diastolic blood pressure of 110 mm Hg or more; with or without symptoms Neurological deficits: all patients with acute onset Sickle cell crisis: all patients Shock: of any etiology
claims per 100 PAs per year ranged from 1.3 in 1981 to 0.1 in 1986. Physicians experienced an average of 10.6 claims per 100 physicians per year in 1980 and 16.5 claims in 1984.13 Comparatively, the average size of award or settlement has been very low for PAs. 14 In our own institution, there h a v e been no m a l p r a c t i c e s u i t s against ED PAs in eight years of Annals of Emergency Medicine
FIGURE. Emergency Services Policy
and Procedure Manual. using full-time PAs. Although functioning under the supervision of the attending physician, the PA should have liability coverage. Individual medical liability policies are available through the 306/133
PHYSICIAN ASSISTANTS Sturmann, Ehrenberg & Salzberg
American Academy of Physician Assistants. Currently, most occurrence liability policies for emergency PAs cost approximately 35% to 40% of an equivalent physician policy. 14 PAs working in institutional settings are normally covered by their employer. In the event that the institution or practice group does not offer the PA liability protection, the supervising physician should notify the insurance carrier of the addition of a PA to the practice. In these cases, a surcharge is usually added to the physician's liability policy covering the PA.
THE PHYSICIAN ASSISTANT P R O G R A M AT BETH ISRAEL MEDICAL CENTER Beth Israel Medical Center is a 932-bed urban tertiary-care hospital located on Manhattan's Lower East Side. The ED has a case load of approximately 60,000 patient visits a year with an admission rate of 25%. The ED currently has 13 full-time emergency medicine attendings providing 24-hour-a-day coverage. Residents rotating from emergency medicine, medicine, surgery, and pediatrics also are present on a 24-houra-day basis. There are now 15 fulltime PAs who provide primary-care and triage coverage 24 hours a day and seven days a week. The large number of PA full-time equivalents is a testimony to the acceptance of PAs in the ED by hospital administrators, medical staff, and the community Beth Israel serves. The PA staff is supervised by a chief PA, who is responsible for the administrative aspects of the program including hiring, evaluations, orientation, discipline, scheduling, and continuing medical education. Approximately one third of the staff are senior PAs. They must have at least three years of clinical experience, two of which must be in the medical center. Promotion is based on individual clinical ability and administrative initiative. The senior PAs share in the supervision and orientation of the new PAs and PA students. Since 1980, Beth Israel has served as a clinical site for PA students from the Long Island University-Brooklyn Hospital PA program. This has added an important dimension to our program. The demands of teaching make for a more stimulating academic en134/307
vironment for our staff. In addition, the graduated students have provided a pool of potential new employees with which we have first-hand experience. The majority of the PA staff were initially students at Beth Israel. There is an extensive orientation and probationary period for teaching our policies and procedures, and each new employee completes a documented in-service. We have found that training new graduates, chosen for their fund of knowledge and positive attitude, is more successful than attempting the retraining of more experienced PAs. The PAs provide primary patient care in both the general treatment and the fast track areas. The protocol that governs their work is a two-part treat and release policy that has been approved by the medical board of the medical center (Figure). Part 1 of this policy enumerates types of conditions the PAs are permitted to evaluate, treat, and release without prior consultation once they have docum e n t e d c o m p e t e n c y and, t h u s , passed probation. This list contains many of the common ED presenting c o m p l a i n t s such as m i n o r lacerations, sprains, strains, skin rashes, urinary tract infections, upper respiratory infections, venereal diseases, and minor febrile illnesses. After probation, even though these cases may be discharged without consultation, all of the cases are reviewed, and the charts are countersigned by an ED attending before the end of the PA's shift. This ensures close supervision of the PAs by the attending faculty. The second part of the policy lists the types of conditions that must be presented to an attending before disposition. Our emphasis has been to select and instill in the PA staff a conservative attitude. Many more cases are presented than are actually dictated by the policy. The result is good, careful, well-documented patient care. Most importantly, a relationship between PAs and attendings exists, based on trust, that the PA will not go beyond their limitations. The cornerstone of our success has been engendering the attitude that if the PA has a question or a doubt, he asks for help. Clinically, the PAs evaluate and treat patients in both the general treatment area and the "fast track." The fast track is used for patients with m i n o r medical and surgical Annals of Emergency Medicine
problems and is staffed exclusively by PAs. The PAs also triage all walkin patients. In addition to making the initial assessment and setting the medical priority, the PA orders pertinent laboratory studies and radiographs. This expedites patient care by obtaining needed data during what would otherwise be only waiting time. Triage has traditionally been a nursing function, but because a registered nurse cannot order diagnostic tests, we have found it to be more efficient to use PAs in this settingA s The third major area of responsibility for the PA staff is our aftercare quality assurance program. One PA is assigned on a rotating basis to this full-time responsibility. All of the ED charts are reviewed within 48 hours after the ED visit for both preestablished follow-up criteria and for specific appropriateness monitors. If indicated by one of the criteria for follow-up (age over 65 years, fever higher than 38.3 C, vaginal bleeding, asthma, abdominal, or chest pain), the PA will make at least three att e m p t s to c o n t a c t the p a t i e n t to check on his condition. If the patient's condition warrants, recommendations may include a return for further evaluation to the ED or to a private physician. The follow-up PA is also responsible to recall by telephone or telegraph patients for significant abnormal laboratory values or radiographs. We believe that the risk reductions, i m p r o v e d p u b l i c image, and enhanced quality of care generated by this follow-up program easily justify the additional PA salary full-time equivalent.
CRITICAL APPRAISAL i In the past eight years, PAs at Beth Israel Medical Center have treated more than 80,000 ED patients. All ambulatory patients are first seen and triaged by a PA. Even with this large experience, there have been no medical malpractice suits initiated by patients attended to by PAs. With minor problems, because of the permanent nature of the PAs in our department, it has been relatively easy to take corrective action. Individual counseling with the PA supervisor is done as needed to improve areas of deficiency. While shift work in any busy ED can become tiring, our PAs have rotating responsibilities to maintain a 19:3 March 1990
h i g h l e v e l of s a t i s f a c t i o n . O n e p e r s o n a w e e k is a s s i g n e d to t h e f o l l o w - u p s y s t e m a n d t h e r e b y is r e l i e v e d of all c l i n i c a l d u t i e s for t h a t w e e k . C l i n i c a l r e s p o n s i b i l i t i e s are d i v i d e d b e t w e e n triage, fast track, and the general treatment area and are usually c h a n g e d o n c e p e r shift. A c l i n i c a l rot a t i o n t h r o u g h t h e a c u t e c a r e area, working directly with an ED attending, s e r v e s as a s t i m u l a t i n g e d u c a tional break from the routine schedule.
v i s i n g p h y s i c i a n (Figure). P r o b l e m cases may be reviewed in the standard fashion at department morbidity a n d m o r t a l i t y c o n f e r e n c e s as w e l l as through individual counseling and discussion with the PA supervisor. Close involvement in all department continuing medical education a c t i v i t i e s s e r v e s a n e d u c a t i o n a l role a n d s t r e n g t h e n s t h e r e l a t i o n s h i p of the PA to the other health care workers within the department.
SUMMARY RECOMMENDATIONS PAs have been employed in a wide v a r i e t y of c l i n i c a l s e t t i n g s to r e n d e r e m e r g e n c y c a r e . t6-18 A l t h o u g h P A s h a v e b e e n s u c c e s s f u l l y u s e d to give p a t i e n t care e v e n w i t h o u t t h e p h y s i cal p r e s e n c e of a s u p e r v i s i n g a t t e n d ing, on-site supervision by emergency medicine-trained attending p h y s i c i a n s is r e c o m m e n d e d . 18 P A s c a n b e e s p e c i a l l y h e l p f u l i n large-volu m e u r b a n E D s s u c h as t h e m o d e l described above. Other authors have d e s c r i b e d t h e s u c c e s s of u s i n g P A s i n s i m i l a r s e t t i n g s . 19 M o d e r a t e - v o l u m e E D s w i t h a n occ a s i o n a l n e e d for a d d i t i o n a l c o v e r a g e b u t w i t h o u t t h e v o l u m e to j u s t i f y t h e h i r i n g of a n a d d i t i o n a l a t t e n d i n g p h y s i c i a n m a y do w e l l w i t h a P A to augm e n t p a t i e n t care. E D s w i t h a h i g h seasonal or hourly variation could m a k e u s e of P A s b y d i v i d i n g t i m e for c l i n i c a l d u t i e s d u r i n g t i m e s of h i g h census and nonclinical duties during t i m e s w h e n t h e p a t i e n t v o l u m e is 10w. P A s are w e l l - t r a i n e d a n d d e d i c a t e d m e m b e r s of t h e h e a l t h c a r e t e a m . T h e y are n o t t r a i n e d a n d n o t l i c e n s e d to a c t i n d e p e n d e n t l y of p h y s i c i a n supervision. On-site supervision with frequent case discussions and chart review helps ensure quality patient care. W e l l - d e f i n e d t r e a t m e n t p r o t o cols permit PAs to treat and discharge patients efficiently and without unnecessary burden on the super-
19:3 March 1990
D u r i n g t h e p a s t 20 years, PAs h a v e b e c o m e a n i m p o r t a n t p a r t of t h e health care delivery team. We have d e s c r i b e d o u r e x p e r i e n c e u s i n g PAs as p r i m a r y p r o v i d e r s i n a n a c t i v e , urb a n ED. W e b e l i e v e t h a t t h e p r i n c i p l e s a n d r e c o m m e n d a t i o n s set f o r t h w i l l lead t o a n e x p a n d i n g role for PAs i n e m e r g e n c y m e d i c i n e t h a t w i l l result in cost-effective, quality patient care. The authors gratefully acknowledge the tireless efforts of Diana Cerrato, Amelia Jecewski, Angola Ellebry, and Daniel Orenstein in the preparation of the manuscript.
REFERENCES 1. Franaszek JB (presenter): Statement of the American College of Emergency Physicians to the Council on Graduate Medical Education. Washington, DC, November 20, 1987. 2. American College of Emergency Physicians: Guidelines for emergency department physician staffing. Ann Emerg Meal 1984;13:1165-1166. 3. Rosenbaeh ML, Harrow B, Crowell J: A pro ~ file of emergency physicians, 1984-1985: Demographic characteristics, practice patterns, and income. Ann Emerg Med t986;15:1261-1267. 4. Buchanan JR: Financing Graduate Medical Education: Final Report of the A A M C Committee on Financing Graduate Medical Education.
Washington, DC, Association of American Med ical Colleges, 1986. 5. Sadler AM, 8adler BL, Bliss AA: The Physi clan Assistant Today and Tomorrow, ed 2. Cambridge, Massachusetts, Ballinger Press, 1975, p 87. 6. Carter RD, Perry HB: Alternatives in Health - -
Care Delivery: Emerging Roles for Physician
Annals of Emergency Medicine
Assistants. St Louis, Missouri, Warren H Green,
Inc, 1984, p 244. 7. US Department of Health and Human Services, Public Health Service, Health Resources Administration: Report of the Graduate Medical Education National Advisory Committee (GMENAC) to the Secretary, Department of Health and Human Services, Volume 171."Nonp h y s i c i a n Health Care Provider Technical Panel. Washington, DC, US Government Print-
ing Office, vol 6, 1980, p 9. 8. The New York State Society of Physician Assistants: The Employment and Utilization of the Physician Assistant ir~ New York State, ed 2. Albany, New York State Society of Physician Assistants, 1988, p 14. 9. Weston J: Distribution of nurse practitioners and physician assistants: Implications of legal constraints and reimbursement. Public Health Reports 1980;95:253-258. 10. Sox H: Quality of patient care by nurse practitioners and physician consultants: A 10 year perspective. Ann Intern Med 1979; 91: 459-468. 11. US Department of Health, Education, and Welfare, Public Health Service, Health Resources Administration: Report of the Physician E x t e n d e d Workgroup. Washington, DC, US Government Printing Office 1977, p 43-53. 12. Ryser J: PAs seen as asset in liability crisis. American Medical News 1976;19:1. 13. American Academy of Physician Assistants Task Force on Professional Liability Report to the House of Delegates: Medical Malpractice and the Physician Assistant Profession - An Overvie~z Arlington, Virginia, American Acad-
emy of Physician Assistants, 1987, p 14. 14. American Academy of Physician Assistants Task Force on Professional Liability Report to the House of Delegates: Medical Malpractice and the Physician Assistant Profession - An Overvie~ Arlington, Virginia, American Acad-
emy of Physician Assistants, 1987, p 11. 15. New York State Nursing Regulations: Arti cle 139, Section 6902, paragraph 1. 16. Maxfield RG, Lemire DR, Wansleben TO: Utilization of supervised physician's assistants in emergency room coverage in a small rural c o m m u n i t y hospital. J T r a u m a 1975;15: 795-799. 17. Cawley JF, Ott JE, DeAtley CA: The future for physician assistants. Ann Intern Med 1983; 98:993-997. 18. Newkirk W: Rural emergency department coverage. J Maine Med Assn 1980;71:375-377. 19. Goldfrank L, Corso T, Squillacote D: The emergency services physician assistant: Results of two years' experience. Ann Emerg Med 1980; 9:96-99.
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Physician Assistants in Emergency Medicine Physician assistants (PAs) specially trained in emergency medicine can be used effectively to work with emergency medicine physicians to provide efficient and expedient high-quality patient care. The concept of using PAs in the emergency department is reviewed, and items of concern to professionals who are reluctant to use PAs are discussed. Financial issues and malpractice risk are examined, and our experience with patient perceptions is summarized. The PA program at Beth Israel Medical Center is used as a case study to demonstrate the use and integration of the PA within the division of emergency services. Although a well-trained emergency physician is the gold standard for quality patient care, cost-effective quality care for certain patient complaints can be rendered acceptably by others. [Sturmann KM, Ehrenberg K, Salzberg MR: Physician assistants in emergency medicine. Ann Emerg Med March 1990;19:304-308.]
INTRODUCTION Physician assistants (PAs) are midlevel health professionals qualified by academic and clinical training to perform tasks traditionally reserved for the physician. They are trained to take histories and perform physical examinations, to order and interpret diagnostic tests, to perform procedures such as suturing and casting, and to diagnose and manage many common health problems. PAs are dependent health professionals who work under the supervision of a licensed physician and often are called "physician extenders" because of their ability to perform delegated responsibilities in the diagnostic and therapeutic management of patients. Currently, there are 50 PA programs nationwide, all accredited by the Joint Review Committee on Educational Programs for Physician Assistants under the auspices of the American Medical Association. Depending on academic prerequisites, the curriculum design and length of study vary from two to four years. In addition to the primary-care PA programs, there are graduate and postgraduate programs in specialty areas such as emergency medicine, anesthesiology, pediatrics, and surgery. The graduate receives a PA certificate, which allows him to be registered and sit for the national certification examination, which was developed by the National Board of Medical Examiners and is administered by the National Commission on Certification of Physician Assistants. A certified PA must pass the examination, complete 100 hours of continuing medical education credits every two years, and take a mandatory recertification examination every six years. PAs are the only allied health professions who have a self-regulatory system with a periodic mandatory recertification examination. All states except New Jersey have legislation governing the use of PAs. Requirements pertaining to registration and certification, as well as prescriptive privileges, vary according to state regulations. The graduate PA is trained in primary care, and specialization is accomplished by either postgraduate studies or on-the-job training. The training and certification process, which emphasizes the recognition of limitations and the need for consultation, establishes the PA as a midlevel health care worker well suited to become an integral part of the emergency department medical team.
19:3 March 1990
Annals of Emergency Medicine
Kai M Sturmann, MD Kathleen Ehrenberg, PA-C Marc R Salzberg, MD, FACEP New York, New York From Emergency Services, Beth Israel Medical Center, New York, New York. Received for publication February 6, 1989. Revision received October 18, 1989. Accepted for publication November 28, 1989. Address for reprints: Kai Sturmann, MD, Emergency Services, Beth Israel Medical Center, First Avenue at 16th Street, New York, New York.
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PHYSICIAN ASSISTANTS Sturmann, Ehrenberg & Salzberg
PHYSICIAN SUPPLY A N D D E M A N D FOR EMERGENCY CARE There is a current shortage of approximately 14,000 emergency physicians. 1 At this time, approximately 8,000 emergency physicians are certified by the American Board of Emergency Medicine. The American College of Emergency Physicians maintains that all physicians working in EDs should be board certified in emergency medicine, z While this goal is echoed by hospital administrators, ED directors, and governm e n t regulators, the fact remains that only 36% of physicians currently practicing in hospital EDs are board certified. 3 With existing residency training positions allowing for approximately 450 graduates a year, attrition needs for retirement, death, and disability are not being met. Clearly, the realization of EDs staffed t o t a l l y by e m e r g e n c y m e d i c i n e board-certified physicians is many years away.
providing patient care, it is likely that decreasing government funding and tighter control over residents' w o r k i n g h o u r s will decrease the availability of such residents. 4 Also, because of the additional time required for teaching and supervision, resident physicians m a y not add a positive net effect to patient flow. In our experience, once PAs have been trained and are oriented to the d e p a r t m e n t , t h e y require significantly less supervision than do residents from rotating specialties. The use of patient care protocols without necessary m o n t h l y orientations results in a more predictable quality of care. Quality assurance is easier to manage when dealing with full-time health care providers. While some residents are extremely capable, efficient, and hard working, others see their rotation through the ED as an undesirable obligation. The PA may be a better alternative than the use of off-service residents.
PATIENT PERCEPTIONS THE PHYSICIAN ASSISTANT AS A N ALTERNATIVE TO TRADITIONAL COVERAGE H o s p i t a l EDs u n a b l e to a t t r a c t qualified full-time attending physicians frequently revert to " m o o n lighting physicians" to temporarily fill schedule vacancies. A l t h o u g h many of these physicians are highly capable practitioners, m a n y are ill equipped to deal with the variety of pathologies presenting to a full-service ED. In this situation, the PA trained in emergency medicine and closely s u p e r v i s e d by a certified emergency physician is able to render superior patient care at a lower cost. Because moonlighting physicians may only work a few shifts a month in the ED, full-time PAs constitute a far more stable force. As such, the PA may become more familiar with the physical layout as well as with the functional aspects of the department. One PA working within well-defined protocols and under the guidance of a full-time attending will be easier to s u p e r v i s e t h a n several moonlighting physicians, resulting in better quality assurance. Scheduling will be simplified because fewer individuals need to be considered when making up a schedule. Even for t h o s e EDs f o r t u n a t e enough to have rotating residents 132/305
Patient perception of the PA is overwhelmingly positive. Time-motion studies have shown that when a PA is used, waiting periods are reduced and patients receive greater attention from various health professionals. 5 In our own institution, unsolicited letters from patients concerning the care rendered by PAs are ten times more likely to be favorable than unfavorable. In a 1981 National Survey of Physician Assistants, 95.7% of the 4,822 PAs surveyed rated acceptance by patients as either good or excellent. Indeed, it was perceived that patient acceptance of PAs was significantly better than the acceptance of PAs by physicians and nurses. 6 A favorable response by the patient population is one of the reasons that a PA program is considered a good risk management tool.
COST ANALYSIS The Graduate Medical Education National Advisory Committee, after a study involving general practice outpatient visits, concluded that PAs could be substituted for physicians at a ratio of 0.5:1 to 0.75:1 when the number of patients was used as the output measure. 7 This number is at best a rough approximation because the study did not consider PAs in an ED. In addition, productivity meaAnnals of Emergency Medicine
sured in terms of patient visits will vary greatly depending on whether a PA or an attending physician was assigned to work a fast track, an acute care, or a general treatment area. The average annual salary for a certified PA in the Northeast is about 40% of the average salary for a boardcertified attending emergency physician. 8 It is clear that using even a low PA-to-physician productivity ratio of 0.5:1, PAs still provide high-quality medical care at a lower cost. The majority of third-party payers, such as major insurance companies and Medicaid and Medicare, reimburse institutions or practice groups at t h e s a m e r a t e r e g a r d l e s s of whether the patient is seen only by an attending physician or by the PA who is supervised by the attending. 9 Reduction of ED waiting time significantly reduces malpractice liability and increases patient volume, which will lead to increased financial reimbursement to the institution. Ultimately, these savings could be passed on to the health care consumer by reducing patient charges.
QUALITY OF CARE--RISK MANAGEMENT A N D MALPRACTICE CONCERNS Central to any discussion of alternatives in health care delivery is the issue of quality of care. Several indepth studies have concluded that the quality of medical services provided by PAs is generally equal to the quality of services provided by physicians.lO, ll Chart documentation by PAs is remarkably detailed and complete, e s p e c i a l l y c o m p a r e d w i t h house officer charting. This demonstrates how the consistency offered by an ED-based PA impacts on quality of care. Poor d o c u m e n t a t i o n is also more easily addressed with the PA because of the more permanent nature of the position. On a larger scale, the quality of patient care can be reviewed by looking at malpractice claims involving PAs. The limited data available, however, apply to all PAs in clinical practice - not just those working in an ED. The Assistant General Counsel to the American Medical Association, addressing the National Conference of the American Academy of Physician Assistants, remarked that, "after looking at the ways in which PAs perform their services, I feel PAs probably hold the potential for being 19:3 March 1990
Subject: Physician Assistant Treat and Release Policy I Poficy: Patients presenting in the emergency department with the following complaints may be evaluated and referred by the examining physician assistant without being seen by an attending physician: All venereal disease in men; the following venereal disease in women: monilia, trichomonas, scabies, and lice Urinary tract infection Minor laceration Follow-up on wound check, cast check, suture removal Upper respiratory infections Otitis media and otitis externa Cerumen removal Foreign body removal (uncomplicated) Uncomplicated hepatitis or exposure to hepatitis Low back pain that is chronic and not associated with neurological findings Minor burns Skin rashes Minor gynecological disorders, such as vaginitis and insignificant abnormalities of menstruation Incision and drainage of simple abscesses Conjunctivitis Hemorrhoids Animal bites Chronic peripheral vascular disease Medical clearance for psychiatric patients Normal pregnancy without accompanying medical problems
Referral to specialty service (eg detoxification, abortion, social service) Con sti pation Prescription refills Fatigue or dizziness without associated findings Minor psychiatric disorders Minor symptoms of alcohol or drug withdrawal Allergic reactions not accompanied by shortness of breath, wheezing, or hypotension Bleeding from any orifice that is minor (determined after objective examination) Headache not associated with acute neurological findings Minor febrile illnesses Hypertension that is asymptomatic and accompanied by a diastolic blood pressure of less than 110 mm Hg Shortness of breath not accompanied by cyanosis, upper airway obstruction, or acute respiratory distress Chest pain that is not typical of ischemic chest pain; is not accompanied by syncope, shortness of breath, arrhythmias; and for which an etiology is clear (eg, costochondritis)
Subject: Physician Assistant Treat and Release Policy II Policy: All patients presenting in the emergency department with the following complaints must be evaluated by the attending physician on duty before discharge by the physician assistant: Abdominal pain: all patients Alcohol or drug withdrawal: associated with confusion, hallucinations, fever, seizures, or delirium Allergic reaction: accompanied by shortness of breath, wheezing, or hypotension Arrhythmias: of recent onset or associated with unstable hemodynamics Bleeding: significant bleeding from any orifice confirmed by objective examination Burns: any third-degree burns; second-degree burns of more than 10% of the total body surface; burns of the eyes, ears, face, hands, feet, and perineum; electrical injury; inhalation injury
one of the best malpractice tools available at the present time. 'q2 Because of the variation in reporting claims, disposition of claims, and lack of a central database, it is difficult to determine the exact incidence of medical malpractice claims involving PAs. A US Government Accounting Office medical malpractice study showed that the frequency of 19:3 March 1990
Chest pain: typical of ischemic chest pain or accompanied by syncope, shortness of breath, or arrhythmias Coma or acute change in mental status: all patients Drug overdose: all patients Head trauma: accompanied by loss of consciousness, neurological findings, or other associated injuries Headache: associated with acute neurological findings Heat injury: hypothermia (temperature less than 35 C) or hyperthermia (temperature more than 40.5 C) Hypertension: diastolic blood pressure of 110 mm Hg or more; with or without symptoms Neurological deficits: all patients with acute onset Sickle cell crisis: all patients Shock: of any etiology
claims per 100 PAs per year ranged from 1.3 in 1981 to 0.1 in 1986. Physicians experienced an average of 10.6 claims per 100 physicians per year in 1980 and 16.5 claims in 1984.13 Comparatively, the average size of award or settlement has been very low for PAs. 14 In our own institution, there h a v e been no m a l p r a c t i c e s u i t s against ED PAs in eight years of Annals of Emergency Medicine
FIGURE. Emergency Services Policy
and Procedure Manual. using full-time PAs. Although functioning under the supervision of the attending physician, the PA should have liability coverage. Individual medical liability policies are available through the 306/133
PHYSICIAN ASSISTANTS Sturmann, Ehrenberg & Salzberg
American Academy of Physician Assistants. Currently, most occurrence liability policies for emergency PAs cost approximately 35% to 40% of an equivalent physician policy. 14 PAs working in institutional settings are normally covered by their employer. In the event that the institution or practice group does not offer the PA liability protection, the supervising physician should notify the insurance carrier of the addition of a PA to the practice. In these cases, a surcharge is usually added to the physician's liability policy covering the PA.
THE PHYSICIAN ASSISTANT P R O G R A M AT BETH ISRAEL MEDICAL CENTER Beth Israel Medical Center is a 932-bed urban tertiary-care hospital located on Manhattan's Lower East Side. The ED has a case load of approximately 60,000 patient visits a year with an admission rate of 25%. The ED currently has 13 full-time emergency medicine attendings providing 24-hour-a-day coverage. Residents rotating from emergency medicine, medicine, surgery, and pediatrics also are present on a 24-houra-day basis. There are now 15 fulltime PAs who provide primary-care and triage coverage 24 hours a day and seven days a week. The large number of PA full-time equivalents is a testimony to the acceptance of PAs in the ED by hospital administrators, medical staff, and the community Beth Israel serves. The PA staff is supervised by a chief PA, who is responsible for the administrative aspects of the program including hiring, evaluations, orientation, discipline, scheduling, and continuing medical education. Approximately one third of the staff are senior PAs. They must have at least three years of clinical experience, two of which must be in the medical center. Promotion is based on individual clinical ability and administrative initiative. The senior PAs share in the supervision and orientation of the new PAs and PA students. Since 1980, Beth Israel has served as a clinical site for PA students from the Long Island University-Brooklyn Hospital PA program. This has added an important dimension to our program. The demands of teaching make for a more stimulating academic en134/307
vironment for our staff. In addition, the graduated students have provided a pool of potential new employees with which we have first-hand experience. The majority of the PA staff were initially students at Beth Israel. There is an extensive orientation and probationary period for teaching our policies and procedures, and each new employee completes a documented in-service. We have found that training new graduates, chosen for their fund of knowledge and positive attitude, is more successful than attempting the retraining of more experienced PAs. The PAs provide primary patient care in both the general treatment and the fast track areas. The protocol that governs their work is a two-part treat and release policy that has been approved by the medical board of the medical center (Figure). Part 1 of this policy enumerates types of conditions the PAs are permitted to evaluate, treat, and release without prior consultation once they have docum e n t e d c o m p e t e n c y and, t h u s , passed probation. This list contains many of the common ED presenting c o m p l a i n t s such as m i n o r lacerations, sprains, strains, skin rashes, urinary tract infections, upper respiratory infections, venereal diseases, and minor febrile illnesses. After probation, even though these cases may be discharged without consultation, all of the cases are reviewed, and the charts are countersigned by an ED attending before the end of the PA's shift. This ensures close supervision of the PAs by the attending faculty. The second part of the policy lists the types of conditions that must be presented to an attending before disposition. Our emphasis has been to select and instill in the PA staff a conservative attitude. Many more cases are presented than are actually dictated by the policy. The result is good, careful, well-documented patient care. Most importantly, a relationship between PAs and attendings exists, based on trust, that the PA will not go beyond their limitations. The cornerstone of our success has been engendering the attitude that if the PA has a question or a doubt, he asks for help. Clinically, the PAs evaluate and treat patients in both the general treatment area and the "fast track." The fast track is used for patients with m i n o r medical and surgical Annals of Emergency Medicine
problems and is staffed exclusively by PAs. The PAs also triage all walkin patients. In addition to making the initial assessment and setting the medical priority, the PA orders pertinent laboratory studies and radiographs. This expedites patient care by obtaining needed data during what would otherwise be only waiting time. Triage has traditionally been a nursing function, but because a registered nurse cannot order diagnostic tests, we have found it to be more efficient to use PAs in this settingA s The third major area of responsibility for the PA staff is our aftercare quality assurance program. One PA is assigned on a rotating basis to this full-time responsibility. All of the ED charts are reviewed within 48 hours after the ED visit for both preestablished follow-up criteria and for specific appropriateness monitors. If indicated by one of the criteria for follow-up (age over 65 years, fever higher than 38.3 C, vaginal bleeding, asthma, abdominal, or chest pain), the PA will make at least three att e m p t s to c o n t a c t the p a t i e n t to check on his condition. If the patient's condition warrants, recommendations may include a return for further evaluation to the ED or to a private physician. The follow-up PA is also responsible to recall by telephone or telegraph patients for significant abnormal laboratory values or radiographs. We believe that the risk reductions, i m p r o v e d p u b l i c image, and enhanced quality of care generated by this follow-up program easily justify the additional PA salary full-time equivalent.
CRITICAL APPRAISAL i In the past eight years, PAs at Beth Israel Medical Center have treated more than 80,000 ED patients. All ambulatory patients are first seen and triaged by a PA. Even with this large experience, there have been no medical malpractice suits initiated by patients attended to by PAs. With minor problems, because of the permanent nature of the PAs in our department, it has been relatively easy to take corrective action. Individual counseling with the PA supervisor is done as needed to improve areas of deficiency. While shift work in any busy ED can become tiring, our PAs have rotating responsibilities to maintain a 19:3 March 1990
h i g h l e v e l of s a t i s f a c t i o n . O n e p e r s o n a w e e k is a s s i g n e d to t h e f o l l o w - u p s y s t e m a n d t h e r e b y is r e l i e v e d of all c l i n i c a l d u t i e s for t h a t w e e k . C l i n i c a l r e s p o n s i b i l i t i e s are d i v i d e d b e t w e e n triage, fast track, and the general treatment area and are usually c h a n g e d o n c e p e r shift. A c l i n i c a l rot a t i o n t h r o u g h t h e a c u t e c a r e area, working directly with an ED attending, s e r v e s as a s t i m u l a t i n g e d u c a tional break from the routine schedule.
v i s i n g p h y s i c i a n (Figure). P r o b l e m cases may be reviewed in the standard fashion at department morbidity a n d m o r t a l i t y c o n f e r e n c e s as w e l l as through individual counseling and discussion with the PA supervisor. Close involvement in all department continuing medical education a c t i v i t i e s s e r v e s a n e d u c a t i o n a l role a n d s t r e n g t h e n s t h e r e l a t i o n s h i p of the PA to the other health care workers within the department.
SUMMARY RECOMMENDATIONS PAs have been employed in a wide v a r i e t y of c l i n i c a l s e t t i n g s to r e n d e r e m e r g e n c y c a r e . t6-18 A l t h o u g h P A s h a v e b e e n s u c c e s s f u l l y u s e d to give p a t i e n t care e v e n w i t h o u t t h e p h y s i cal p r e s e n c e of a s u p e r v i s i n g a t t e n d ing, on-site supervision by emergency medicine-trained attending p h y s i c i a n s is r e c o m m e n d e d . 18 P A s c a n b e e s p e c i a l l y h e l p f u l i n large-volu m e u r b a n E D s s u c h as t h e m o d e l described above. Other authors have d e s c r i b e d t h e s u c c e s s of u s i n g P A s i n s i m i l a r s e t t i n g s . 19 M o d e r a t e - v o l u m e E D s w i t h a n occ a s i o n a l n e e d for a d d i t i o n a l c o v e r a g e b u t w i t h o u t t h e v o l u m e to j u s t i f y t h e h i r i n g of a n a d d i t i o n a l a t t e n d i n g p h y s i c i a n m a y do w e l l w i t h a P A to augm e n t p a t i e n t care. E D s w i t h a h i g h seasonal or hourly variation could m a k e u s e of P A s b y d i v i d i n g t i m e for c l i n i c a l d u t i e s d u r i n g t i m e s of h i g h census and nonclinical duties during t i m e s w h e n t h e p a t i e n t v o l u m e is 10w. P A s are w e l l - t r a i n e d a n d d e d i c a t e d m e m b e r s of t h e h e a l t h c a r e t e a m . T h e y are n o t t r a i n e d a n d n o t l i c e n s e d to a c t i n d e p e n d e n t l y of p h y s i c i a n supervision. On-site supervision with frequent case discussions and chart review helps ensure quality patient care. W e l l - d e f i n e d t r e a t m e n t p r o t o cols permit PAs to treat and discharge patients efficiently and without unnecessary burden on the super-
19:3 March 1990
D u r i n g t h e p a s t 20 years, PAs h a v e b e c o m e a n i m p o r t a n t p a r t of t h e health care delivery team. We have d e s c r i b e d o u r e x p e r i e n c e u s i n g PAs as p r i m a r y p r o v i d e r s i n a n a c t i v e , urb a n ED. W e b e l i e v e t h a t t h e p r i n c i p l e s a n d r e c o m m e n d a t i o n s set f o r t h w i l l lead t o a n e x p a n d i n g role for PAs i n e m e r g e n c y m e d i c i n e t h a t w i l l result in cost-effective, quality patient care. The authors gratefully acknowledge the tireless efforts of Diana Cerrato, Amelia Jecewski, Angola Ellebry, and Daniel Orenstein in the preparation of the manuscript.
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ing Office, vol 6, 1980, p 9. 8. The New York State Society of Physician Assistants: The Employment and Utilization of the Physician Assistant ir~ New York State, ed 2. Albany, New York State Society of Physician Assistants, 1988, p 14. 9. Weston J: Distribution of nurse practitioners and physician assistants: Implications of legal constraints and reimbursement. Public Health Reports 1980;95:253-258. 10. Sox H: Quality of patient care by nurse practitioners and physician consultants: A 10 year perspective. Ann Intern Med 1979; 91: 459-468. 11. US Department of Health, Education, and Welfare, Public Health Service, Health Resources Administration: Report of the Physician E x t e n d e d Workgroup. Washington, DC, US Government Printing Office 1977, p 43-53. 12. Ryser J: PAs seen as asset in liability crisis. American Medical News 1976;19:1. 13. American Academy of Physician Assistants Task Force on Professional Liability Report to the House of Delegates: Medical Malpractice and the Physician Assistant Profession - An Overvie~z Arlington, Virginia, American Acad-
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