ORIGINAL RESEARCH
Caring for the disadvantaged: The role of physician assistants Lisa R. Henry, PhD; Roderick S. Hooker, PhD, PA
ABSTRACT Objective: We investigated community health centers (CHCs) and the roles of physician assistants (PAs) within them. Our goals were to broadly describe PA practice characteristics within CHCs, to explore why PAs work in CHCs, and to understand patient perspectives of PAs. Methods: We evaluated 10 CHCs in Texas (5 urban and 5 rural), using an ethnographic approach to examine attitudes and beliefs of PAs, medical staff, and patients. Results: Nine of the 10 clinics used PAs interchangeably with physicians, and most medical staff and patients perceived few differences between them. Patients view all providers as highly effective and genuinely concerned for their patients. Conclusions: We found that clinicians and staff believe in the work they do, report that they function as a team, and seem to like their roles. It appears that working with the medically underserved and economically disadvantaged enables PAs to thrive. Keywords: physician assistant, community health centers, medically underserved, economically disadvantaged
Following World War II, as the proportion of the population who were poor and lacked health insurance rose, access to healthcare became problematic.1 The federal government came to realize that a compassionate society has a clear mission to serve the poor and older adults, and nearly half a century ago launched a series of strategies to address their healthcare needs. The creation of Medicare, Medicaid, and CHCs represents the most notable of these federal efforts.2-6 Lisa R. Henry is associate professor and chair of the department of anthropology at the University of North Texas in Denton, Tex. Roderick S. Hooker is a retired PA. The authors have indicated no relationships to disclose relating to the content of this article. Acknowledgement: This study was made possible with a small grant from the Physician Assistant Education Association Research Institute and the American Academy of Physician Assistants. The authors are indebted to the National Association of Community Health Centers in their critique of the proposal and the Texas Association of Community Health Centers and their efforts to obtain additional funds for a more comprehensive study. Further thanks go to the graduate students and transcribers for their contributions to the project. DOI: 10.1097/01.JAA.0000438532.92138.53 Copyright © 2014 American Academy of Physician Assistants
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CHCs were created in 1965 through federal grant initiatives to provide health and social services access in poor and medically underserved communities across all 50 states, the District of Columbia, and the territories. Funding for CHCs remains a federal function, administered by the Department of Health and Human Services’ Bureau of Health Professions. Yet the decision for how care is delivered, along with medical staffing mix, is made on the local level and is not dictated by government. Physicians, PAs, and NPs have been an integral part of CHC teams since the 1970s. CHCs now have a central role in primary healthcare delivery. In 2009, the American Recovery and Reinvestment Act directed $2 billion to CHCs over 2 years. After the first year, the initiative had reached 2.1 million new patients and 1.2 million new uninsured patients. Under the Patient Protection and Affordable Care Act (ACA), CHCs are at the center of the expansion of accessible and high-value primary healthcare. The ACA includes $11 billion in dedicated funds for CHCs over 5 years, with $9.5 billion of these funds for building new CHCs and improving existing ones. A goal of the ACA is to increase funding for CHCs, so that they could serve 40 million patients by 2015. CHCs will need to add an estimated 15,000 new providers to their staffs by 2015 to meet this goal.7 CHCs have played a critical role both in caring for the uninsured and as model primary healthcare clinics in their communities.8,9 As of 2012, more than 8,000 CHCs were serving the primary healthcare needs of more than 20 million patients across the United States and territories. The mission of most CHCs includes meeting healthcare needs of low-income populations, the uninsured, those with limited English proficiency, migrant and seasonal farmworkers, individuals and families experiencing homelessness, and people living in public housing. Though smaller CHCs might provide solely primary care for their local population, larger CHCs may also offer a federally funded pharmacy, dental care, behavioral therapies, mental health and substance abuse programs, health education, specialized women’s health services, weight loss programs, and other social services such as legal aid, transportation, and case management. Because the vast majority of people served by CHCs are poor or medically disenfranchised, we undertook this study to understand the characteristics and motivations of those who work in this setting. Volume 27 • Number 1 • January 2014
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Caring for the disadvantaged: The role of physician assistants
Which healthcare workers are most likely to choose to work with underserved populations and be committed to this type of practice? Rabinowitz and colleagues identified four independent predictors among physicians of choosing to provide care to the underserved: • being a member of an underserved ethnic or minority group • having participated in the National Health Service Corps • having a strong interest in practicing in an underserved area before attending medical school • growing up in an underserved area.10 Scammon and colleagues, who analyzed data from a series of qualitative studies of family practice residency programs, found that those most likely to practice in underserved settings feel a need “to make a difference” and have a desire to return to “roots,” to serve humanity, and to experience challenge and adventure.11 Similarly, Li and colleagues found that a group of health professionals committed to working with the poor had a strong sense of service to humanity and pride in making a difference and appeared to thrive on the challenge of creatively meeting their patients’ complex needs with limited healthcare resources.12 Only a few research studies have specifically addressed the role of PAs and NPs in working with the underserved, especially in rural areas.13-19 In a study conducted in California and Washington State, Grumbach and colleagues found that PAs ranked first or second in each state in the proportion of their members who practice in rural areas.13 Further, a national study found that PAs and NPs are proportionally more likely than physicians to work with rural populations than urban populations in chronic disease encounters.14 Staton and colleagues established that patients who lived in underserved, rural populations that did not have health insurance had higher odds of visiting a PA than patients in urban areas.15 Shi and colleagues found that PAs and NPs primarily serve as physician substitutes in medically underserved areas, where they are important to containing costs and improving access to care.16 Everett and colleagues, too, found that PAs and NPs provide the complexity and level of care that physicians provide with similar outcomes; Henry and colleagues, in a systematic literature review of PAs in rural health, confirmed that PAs are well-suited for this practice setting.17,18 Finally, Huckabee discovered that, compared with other PAs, those practicing in underserved areas have a high level of “leadership servant” qualities, such as an altruistic calling, emotional healing, and wisdom.19 The ACA will affect access to primary care as it expands health services to many groups that traditionally have been underserved and uninsured. Because these changes place strains on the existing workforce, understanding organizational dynamics, clinic culture, and the role of PAs in the provision of care may contribute to healthcare work-
force policies for delivering care to disenfranchised populations.9 Our goal in undertaking this study was to aid in this process by examining the role of PAs in providing care to the medically underserved. We have singled out CHCs for this investigation because they provide primary care and their social mission is to deliver service to the poor. The specific aims of this study are to: • understand the clinic culture of CHCs and PA roles in the provision of care • gain a broader understanding of PA practice characteristics within CHCs • explore why PAs work in CHCs • understand patient perspectives of PA contributions to CHCs. METHODS We used a qualitative, ethnographic approach in this research. Quantitative research generally starts with hypotheses to drive data collection and analysis, but ethnographic research relies on inductive and interactive processes to build theories to explain the behavior and beliefs under study. The process emphasizes exploration and discovery and lets research participants direct interviews in meaningful ways that give additional understanding to the research questions. The goal is to dig deeply into the meanings people give to their behaviors, attitudes, and motivations. This type of methodology provides depth of understanding by observing and interviewing participants in their natural environment. Population and sample This study was undertaken in one state (Texas) primarily to reduce confounding variables of heterogeneous state legislation governing PAs. We visited 10 CHC sites in 2010: five in rural areas (fewer than 10,000 people) and five in urban areas (more than 100,000 people). One principal goal was to highlight the commonalities in PA practice characteristics that override variations in CHC profiles. Preparatory research identified 332 CHC delivery sites in the state, which we then stratified by provider team composition, rural/urban status, and geographic regions. Of the 332 delivery sites, 98 (or 30%) were staffed with a PA. Of the 98 CHCs staffed with a PA, 28 were in rural areas, 48 were in urban areas, and 22 were in population areas out of the scope of this research. We telephoned the CHC office manager of every other CHC in our list of 98, after stratification, and asked permission to visit the clinic and conduct research. We continued down our list in this fashion until 10 clinics confirmed participation that spanned all regions and an equal number of rural and urban clinics. Each clinic received a $200 unrestricted grant to defray the costs of taking providers away from patient care. Office managers and medical directors told clinical staff about the research study and encouraged them to participate. Overall, rates of clinical staff participation were high; PAs and NPs had a 100% participation rate across the 10 clinics (Table 1). Participation rates were also 100% in
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ORIGINAL RESEARCH TABLE 1.
Participation rate of clinical staff
Type of clinician
Total number across clinics
Number who participated in study
PA
11
11
MD/DO
15
10
4
4
RN/LVN
20
16
Medical assistant
14
10
Total
64
51
NP
small rural clinics. No clinicians declined participation if we requested an interview. In large, urban clinics, we did not request interviews with all physicians, nurses, or medical assistants. Data collection A medical anthropologist with a background in health services delivery and health workforce studies led the study team. Specific data collection techniques for this project included semistructured interviews, observations of the general operations of the clinic without entering the examination rooms, and patient questionnaires. The University of North Texas Institutional Review Board approved this project in 2010. We conducted semistructured interviews of the CHCs’ clinical staff (medical and support staff), including PAs, MDs, and doctors of osteopathy (DOs), NPs, nurses, and medical assistants to understand the general CHC culture—that is, attitudes, beliefs, and behaviors—and the role and contributions of PAs, relying on open-ended questions and a conversational style. The data were recorded, transcribed, and cross-analyzed for common themes across all CHCs. We removed all personal identifications. We then combined data from the semistructured interviews with our observations of clinic operations. The 160 hours of recorded observations not only provided insight into how the clinics operate but how the clinical staff interacts with each other and builds rapport. TABLE 2.
Study participants: Urban vs. rural CHCs
Participant type
Rural CHC participants
Urban CHC Total participants participants
PA
5
6
11
MD/DO
4
6
10
NP
2
2
4
11
5
16
3
7
10
Patient
63
62
125
Total
88
88
176
RN/LVN Medical assistant
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To collect patient data, we asked patients to rate (on a scale from 1 to 5) how well PAs performed various functions. Some patients filled out this written survey on their own. Others were guided through the survey orally. We followed these questions with more open-ended queries to elicit how the PA was perceived to contribute to the patient’s treatment and clinic experience. We also collected demographic characteristics of the surveyed patients, including income, education, marital status, gender, ethnicity, and age. We recruited participants from a convenience sample of CHC patients who had at least one clinical visit with the PA on staff at the CHCs on research days. Patients received $10 for participating and we reassured them that identifying characteristics would be removed from the data. Although use of an incentive in survey research is controversial, we decided on this approach after discussion with those experienced in this field, in part because survey participation is known to be quite low in impoverished areas. Patient participants totaled 125, with 63 in rural CHCs and 62 in urban clinics. Of the 51 clinician study participants, PAs, MDs/DOs, and NPs were about equally represented in urban and rural clinics; registered nurses (RNs) and licensed vocational nurses (LVNs, the Texas equivalent of LPN) were primarily in rural settings; and medical assistants mostly in urban CHCs (Table 2). RESULTS Clinical staff characteristics The clinical staff was 78% female, with a mean age of 40 years. Most PAs had been nationally certified for more than 10 years (Figure 1). PAs had been 3.25 years in the current clinic (range, 7 months to 10 years) (Figure 2). Patient characteristics Patients visited the clinic for acute and urgent care (n=44), chronic care (n=22), preventive care (n=21), and follow-up visits (n=18). Twenty patients did not complete this question. Most urgent and acute complaints were for upper respiratory infections or injuries. Chronic care issues included diabetes, hypertension, high cholesterol, and asthma. Most preventive visits were checkups and well woman and well baby examinations. Return visits were for laboratory and imaging procedures or to obtain results. Most patients (84%) reported a household income of less than $25,000 in 2010. Payment for healthcare was predominantly through Medicaid, Medicare, or out-of-pocket (self-pay). A high proportion of patients (61%) were Hispanic, reflecting the predominance of this ethnicity in the state. A plurality of patients (47%) were married; 27% were single, and 26% were divorced, widowed, or separated. Twenty-six percent had less than a high school education, 29% had completed high school or obtained a general equivalency diploma, 11% had vocational training, 19% had taken some college classes, and 15% had earned a degree (ranging from associate’s to doctoral degrees). Seventy-three percent of the patients were women. Ages Volume 27 • Number 1 • January 2014
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Caring for the disadvantaged: The role of physician assistants
ranged from 18 to 75 with fairly equal distribution through the age-groups. CHC models and clinic culture Nine of the 10 clinics used PAs in a similar capacity as physicians: as clinicians with their own panel of patients. PAs maintained their own patient schedule, and patients asked to see a specific provider, be it physician, PA, or NP. Although PAs consulted with physicians on complex cases, they reported that they rarely transferred patients to the physician for follow-up care. In terms of patient preference, some patients with insurance reported they returned to the clinic out of preference for the provider. Most of the staff in the nine CHCs that practiced this broad-based model agreed that patient preference for a particular provider was consistent with desired continuity of care. Although nine of the CHCs had many similarities, one followed a different model, using PAs for same-day appointments; PAs essentially worked triage and acute care. Because of capacity limitations, PAs at this limited-model CHC followed the patients until an appointment could be made with a physician, generally within 1 to 6 months. Once assigned to a physician, the patient could not return to see the PA. The PAs at this limited-model CHC felt that patients lacked continuity of care, and patients there were less pleased with the care they received than were patients at the broad-based CHCs. The overall clinic culture also differed between these two CHC models. In the nine clinics where PAs saw their own patient load, the staff described collegial working relationships. These clinics follow a collaborative team-based strategy in which PAs pose questions to physicians on complicated cases and physicians are available to answer PAs’ questions. Physicians reported that they seek out the PAs about cases as well. But in the CHC that limited PAs to triage and acute care, clinician interviews did not give rise to spontaneous or unprompted discussion of teamwork and collaboration as they did in the other nine clinics. Physicians in the CHC that limited PA practice thought that PAs should be allowed to take on patients when triage was slow to offset physicians’ heavy patient load, but policy prohibited it. Regarding physician supervision, all PAs in all 10 clinics felt they had adequate time with their supervising physician and that the physicians were responsive to PAs if consultation was needed. We did not identify any tension in relationships between physicians and PAs nor did we see any tensions between PAs and NPs or between physicians and NPs in clinics that staff both. Of the 15 physicians interviewed, only two volunteered concerns about use of PAs. Their concerns centered on the liability of a PA medical error, creating more supervisory work for the physician and the potential for damaging the physician’s reputation. According to clinical staff in all CHCs, providers’ relationships with patients were viewed as “trusting,” meaning that the patients believed the providers were providing care in the patients’ best interest. The most detailed and
8 7 6 5 4 3 2 1 0
< 5 years
5-10 years
> 10 years
FIGURE 1. PA years of certification
seemingly candid comments about provider/patient relationships came from nurses and medical assistants. They noted that all providers worked hard to identify treatments the patients could afford and to identify specialists willing to accept the referral. For their part, patients preferred to see their own providers, whether physicians or PAs. One exception to this pattern was at a CHC in a large urban area adjacent to a major public hospital, where many patients have drug-seeking behavior. The support staff there noted that these patients are perhaps more adversarial than patients at other CHCs, particularly when they fail to obtain sought-after medications, and appeared indifferent about the particular provider they saw as long as they obtained their medications. Another exception was the limited-model CHC where PAs worked triage instead of their own patient panel. Although patients reported liking the PAs, they did not have the opportunity to build relationships with them. Nor did these patients have the opportunity to express preference for a provider (PA, NP, or physician). They were assigned to a physician if they needed long-term care at the clinic. Availability of services in CHCs Most clinical staff had positive comments about the availability of services. They volunteered comments about the comprehensiveness of care and sometimes said that patients received better primary care at the CHC than at private practices. Eight of the 10 centers have some specialty care, including dentistry, women’s health, pediatrics, pharmacy, drug cessation programs, weight loss programs, behavioral programs, cardiovascular programs, and other social services, such as legal and transportation. The clinical staff contended that the PAs “bend over backwards” to provide patients with every needed eligible service. PAs also worked to identify specialists willing to accept patients and treat them pro bono. Overall, the clinical and support staff of the CHCs appeared to care about patients and to take pride in serving them well. All of the PAs noted that their patients
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frequently tell them how thankful and grateful they are for their care, for being educated about their health condition, and for referrals to specialists. Anticipated CHC staffing Although most comments about the availability of services by PAs were positive, the clinical staff also had concerns about the future of CHCs. Some believed more clinics were needed, along with private practice physicians willing to accept sliding-scale payments and Medicaid/Medicare reimbursement. Many administrators reported that their CHCs were understaffed and needed more physicians and nurses. Some believed that if they could hire more physicians, they could also hire more PAs and NPs and accommodate more patients. The clinical staff also complained that PAs’ scope of practice was restricted by state legislation, and that they could achieve a broader range of services if restrictions on their roles were lifted. For example, they felt that PAs should have broader prescribing privileges and ability to refer patients to specialty services, instead of needing to clear these with a physician. A leading patient complaint was lengthy wait times between visits. PA practice characteristics Clinical staff estimate that PAs provide 85% to 90% of the range of services that physicians provide. Significantly, most CHC clinical staff (67%) perceived no difference between physicians and PAs in their scope of practice. The staff reported that patients rarely switch providers in the nine clinics where PAs provide primary care. Physicians listed some of the roles in CHCs that PAs do not have, including: • handling complicated cases, often involving chronic and progressive comorbidities • signing off on referrals, making home health visits, performing some minor surgeries, and prescribing Schedule II controlled substances for Medicaid and Medicare patients • reviewing medical records for quality of care • serving in a supervisory and mentoring role. In probing for differences between PAs and physicians, we heard that PAs are more likely to have “soft skills.” According to nurses and medical assistants, PAs have a holistic approach to patient care. Our overall impression is that when compared with physicians, PAs were seen as: • looking at the whole patient rather than the chief complaint • spending time talking with patients • providing more patient education • being flexible in management decisions • being collegial with nurses • more concerned than physicians with helping patients find social services. The vast majority of clinical staff also reported that PAs take more time with their patients than physicians (although the study did not verify this). The average length of appointment time varied between 15 and 20 minutes, depending on the case. Some acute cases took 5 to 10 minutes, and some chronic cases could take 20 minutes. One PA said 40
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5 4 3 2 1 0 < 1 year
1-3 years
4-6 years
> 6 years
FIGURE 2. PA years at current clinic
she takes every minute of the 20 minutes she is allotted per patient to check over the patient’s entire body or educate him or her on a particular issue. PAs report they initiate patient education even in the absence of questions. Because CHCs use PAs and NPs interchangeably in clinical roles, these clinical comments could be applied to NPs as well. However, the patient interview data revealed a few perceived differences between PAs and NPs: • PAs are more like physicians than NPs are because PA training is similar to physician training. • PAs are better trained, more autonomous, and have stronger clinical skills than NPs (a perception only of physicians) • Compared with PAs, NPs are more like nurses, are more empathetic to nurses, and will sometimes perform nurses’ tasks if necessary. All three types of clinicians reported that they enjoyed the openness and accessibility of patient relationships as well as the range of patients they see and help. Nearly all clinical and support staff noted that the most positive aspect of their work is the gratification they feel in being able to treat patients, especially those who are disadvantaged. All health professionals believe that they were able to have a positive effect on their patients’ lives and feel rewarded when they see their patients’ health improve. Almost all the PAs enjoy their working environments and the closeknit relationships they have with patients, physicians, nurses, and coworkers. For many clinicians, however, patients are also the number one cause of frustration in their work. Clinicians cited the high patient volume, patients who do not follow the provider’s prescriptions or recommendations, and patients’ low health literacy. PAs mentioned being frustrated by long work hours, a lack of resources, understaffing, and not having enough autonomy to complete certain tasks. Patient perspectives Patients gave PAs high ratings in response to the specific questions we asked about their Volume 27 • Number 1 • January 2014
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Caring for the disadvantaged: The role of physician assistants
experience with PAs at CHCs. TABLE 3. Patient perspectives of physician assistants With a highest possible rating Scores are rated on a scale of 1 (lowest) to 5 (highest). of 5, mean ratings were either 4.8 or 4.9 for each of the 10 Question Mean score questions we posed (Table 3). How courteous and respectful was the PA? 4.9 In answer to the open-ended questions, most respondents How well did the PA listen to your concerns and questions? 4.8 indicated that the PA was highly How well do you think the PA understood your problem? 4.8 effective, efficient, and knowlHow well did the PA explain to you what he or she was doing and why? 4.8 edgeable and seemed genuinely to care about patients. Many Did the PA use words that were easy for you to understand? 4.9 said they “loved” their PA. How satisfied are you with the amount of time the PA spent with you? 4.8 Most patients emphasized that the treatment and care the PAs How much confidence do you have in the PA’s ability or competence? 4.7 provided was helpful. Many How likely are you to recommend the PA to others? 4.8 said that the PA was an effective educator about treatments and How likely are you to schedule appointments with the PA in the future? 4.8 diagnoses and expressed appreOverall, how satisfied are you with the service that you received from the PA? 4.8 ciation for this education and considered it important. We heard only five negative patient comments; they related to are recognized for their skills and tasks that contribute to how the PA seemed too busy, could not perform the duties positive health outcomes for patients, and are trusted by a physician could, or made no attempt to make a personal clinical staff and patients. Because of regulations, PAs are connection. unable to perform a few tasks, and these limitations seem Most respondents said they chose to see the PA out of a to frustrate clinical staff. sense of loyalty. Patients expressed a connection or felt Health professionals working with the economically they had a personal history with the PA that they valued. disadvantaged are a small minority of workers. Their chalOther significant reasons patients cited for seeing the PA, lenges differ from those faced by clinicians whose patients however, were assignment to the PA by the appointment are more affluent or have adequate health insurance. desk or because the physician was unavailable. Some Disadvantaged patients often present complex social as patients mentioned that the PA was highly recommended well as medical issues; for example, identifying a specialist by friends or other providers. Only 7 patients (5.6%) cited willing to take patients pro bono or on a sliding scale is a finances as the reason they were at the clinic seeing the PA. time-consuming task that generally does not fall on a When asked what unique contributions the PAs made private practice clinician. This social challenge may be a to the clinic, most patients used words such as effective, defining characteristic of practicing in a CHC and needs considerate, personable, and genuine. Thirteen patients further exploration. noted that PAs did not seem to make unique contributions Any disadvantages of working with an economically to the clinic. Only two patients noted that PAs and NPs disadvantaged population did not seem to matter to the contribute to the clinic by being cost effective. staff, however. Indeed, it appears that PAs who work in underserved areas are personally drawn to working in this DISCUSSION environment. Yet it may be that the positive organizational This onsite assessment of PAs who are working with eco- dynamics and clinic culture of CHCs—elucidated in this nomically disadvantaged patients in CHCs reveals a prostudy—are the chief factors that help PAs thrive in CHCs. vider workforce that seems to be well-integrated with staff, Patients report high levels of satisfaction with PAs and patients, and the clinical operation. The workload seems tend to seek them out as their primary care provider. Only similar to that of physicians, with little division of labor a few patients make much distinction between PAs and in 9 of the 10 CHCs. All 10 CHCs appear highly functional, physicians. Nonetheless, a recent survey by Dill and coland almost all providers seem to be carrying a similarly leagues shows that patients are open to even greater roles large panel of patients. The PAs in this study apparently for PAs and NPs.20 are content with their roles, which is reflected in long-term PAs seem to have “soft skills” that may differ from those retention. The overlap of clinical roles seems consistent of physicians. This term has not been fully defined in the with team-based care and only in the limited-model CHC literature but has been mentioned by some observers. did any significant differences emerge in how PAs were Cohen believes that soft skills comprise problem solving, used compared with physicians. Overall, PAs appear to collaboration, cultural competence, and team leadership.21 like their coworkers, enjoy the collegiality of the workplace, Additional research is needed to understand how some JAAPA Journal of the American Academy of Physician Assistants
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CHCs are able to thrive and expand while others struggle to stay afloat. Although the division of labor and economy of scale are important determinants of efficiency, CHC research has not addressed the dynamics provided by the collective effort of a team to effect change. Job satisfaction, managing multiple chronic conditions, team-based care models, subspecialist referral, and increasing demand are some of the issues that CHCs confront. Policy implications Most analyses show that the projected number and distribution of physicians will be inadequate to meet healthcare demands in this decade.22,23 The growth and aging of the population, chronic diseases, increasing visits per capita, and new technology will not keep pace with the demand for services.22 Most workforce analysts believe that as CHCs expand they will rely on PAs and NPs more than ever. This review of one state’s CHC experience suggests that PA use may be limited by regulation that could be more expansive and permissive. PAs may prescribe on their own signature in many states, and the liability is considered low.24 Expanding full prescribing authority in all states would improve efficiency in workflow. Also, the “incident to” clause in Medicare and Medicaid reimbursement discounts the rate to 85% of the prevailing physician fee, a clause that seems outdated and inadequate for compensation of high-value services. Full reimbursement would permit more efficiency in meeting patient needs and adequately remunerating providers for services rendered. LIMITATIONS Like all qualitative, ethnographic research, this study was exploratory and emphasizes discovery. Our findings can be used as a foundation for additional quantitative research. Though our goal was to study PAs, we included NPs in the research on clinic culture if PAs and NPs were employed in the same clinic. We did so because well into the investigation we confirmed that PAs and NPs have interchangeable roles at CHCs. Confining our study to Texas also could be considered a study limitation. We selected these CHCs because they are as representative as possible of CHCs in North America, but also are distinguishable, geographically diverse, and culturally different. CONCLUSION CHCs, developed as a way to help those who remained disenfranchised after Medicare and Medicaid were enacted, brought in PAs as a workforce innovation.25 Delivering healthcare to the medically underserved and economically disadvantaged is a role that PAs have taken on in full partnership with physicians, nurses, and other health professionals. This ethnographic research showed that multidisciplinary primary care is performed well in CHCs by a cohesive body of clinicians and staff who believe in the work they do and function as a team. JAAPA 42
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REFERENCES 1. Stevens RA. Health care in the early 1960s. Health Care Financ Rev. 1996;18(2):11-22. 2. Rosenbaum S, Hawkins DR, Rosenbaum E, et al. State funding of comprehensive primary medical care service programs for medically underserved populations. Am J Public Health. 1998;88(3):357-363. 3. Hawkins DR, Rosenbaum S. The challenges facing health centers in a changing healthcare system. In: Altman SH, Reinhardt UE, Shields AE, eds. The Future US Healthcare System: Who Will Care for the Poor and Uninsured? Chicago, IL: Health Administration Press; 1998. 4. Dievier A, Giovannini T. Community health centers: promise and performance. Med Care Res Rev. 1998;5(4):405-431. 5. Politzer, RM, Yoon J, Shi L, et al. Inequality in America: The contribution of health centers in reducing and eliminating disparities in access to care. Med Care Res Rev. 2001;58(2):234-248. 6. Adashi E, Geiger H, Fine M. Health care reform and primary care—the growing importance of the community health center. New Engl J Med. 2010;362(22):2047-2050. 7. CHC’s Law, Explanation and Analysis of the Patient Protection and Affordable Care Act, Volume 1: Including Reconciliation Act Impact. Aspen Publishers. 2010. 8. Goldman LE, Chu PW, Tran H, et al. Federally qualified health centers and private practice performances on ambulatory care measures. Am J Prev Med. 2012;43(2):142-149. 9. Lo Sasso AT, Byck GR. Funding growth drives community health center services. Health Aff. 2010;29(2):289-296. 10. Rabinowitz HK, Paynter NP. The role of the medical school in rural graduate medical education: pipeline or control valve? J Rural Health. 2000;16(3):249-253. 11. Scammon, DL, Li LB, Williams SD. Increasing the supply of providers for the medically underserved: marketing and public policy issues. J Public Policy Mar. 2008;14(1):35-47. 12. Li, LB, Williams SD, Scammon DL. Practicing with the urban underserved: a qualitative analysis of motivations, incentives, and disincentives. Arch Fam Med. 1995;4:124-133. 13. Grumbach K, Hart GL, Mertz E, et al. Who is caring for the underserved? A comparison of primary care physicians and nonphysician clinicians in California and Washington. Ann Fam Med. 2003;1(2):97-104. 14. Hooker RS, Benitez J, Coplan B, Dehn RW. Ambulatory and chronic disease care by physician assistants and nurse practitioners J Ambulatory Care Manage. 2013;36(4)(in press). 15. Staton, FS, Bhosle MJ, Camacho FT, et al. How PAs improve access to care for the underserved. JAAPA. 2007;20(6):32-36. 16. Shi L, Samuels ME, Ricketts TC III, Konrad TR. A rural-urban comparative study of nonphysician providers in community and migrant health centers. Public Health Rep. 1994;(109)6:809-815. 17. Everett CM, Schumacher JR, Wright A, et al. Physician assistants and nurse practitioners as a usual source of care. J Rural Health. 2009;25(4):407–414. 18. Henry LR, Hooker RS, Yates KL. The role of physician assistants in rural health care: a systematic review of the literature. J Rural Health. 2011;27(2):220-229. 19. Huckabee MJ. Physician assistants as servant leaders: meeting the needs of the underserved. J Physician Assist Educ. 2011;22(4):6-14. 20. Dill MJ, Pankow S, Erikson C, Shipman S. Survey shows consumers open to a greater role for physician assistants and nurse practitioners. Health Aff. 2013;32(6):1135-1142. 21. Cohen PM. Building the right skills for the healthcare workforce of the future. JAAPA. 2013;26(7):7-8. 22. Sargen M, Hooker RS, Cooper RA. Gaps in the supply of physicians, advance practice nurses, and physician assistants. J Am Coll Surg. 2011;212(6):991-999. 23. Petterson SM, Liaw WR, Phillips RL, et al. Projecting US primary care physician workforce needs: 2010-2025. Ann Fam Med. 2012;10(6):503-509. 24. Hooker RS, Nicholson J, Le T. Does the employment of physician assistants and nurse practitioners increase liability? J Med Licensure Discipline. 2009;95(2):6-16. 25. Cawley JF, Cawthon E, Hooker RS. Origins of the physician assistant movement in the United States. JAAPA. 2012;25:36-42. Volume 27 • Number 1 • January 2014
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Caring for the disadvantaged: The role of physician assistants Lisa R. Henry, PhD; Roderick S. Hooker, PhD, PA
ABSTRACT Objective: We investigated community health centers (CHCs) and the roles of physician assistants (PAs) within them. Our goals were to broadly describe PA practice characteristics within CHCs, to explore why PAs work in CHCs, and to understand patient perspectives of PAs. Methods: We evaluated 10 CHCs in Texas (5 urban and 5 rural), using an ethnographic approach to examine attitudes and beliefs of PAs, medical staff, and patients. Results: Nine of the 10 clinics used PAs interchangeably with physicians, and most medical staff and patients perceived few differences between them. Patients view all providers as highly effective and genuinely concerned for their patients. Conclusions: We found that clinicians and staff believe in the work they do, report that they function as a team, and seem to like their roles. It appears that working with the medically underserved and economically disadvantaged enables PAs to thrive. Keywords: physician assistant, community health centers, medically underserved, economically disadvantaged
Following World War II, as the proportion of the population who were poor and lacked health insurance rose, access to healthcare became problematic.1 The federal government came to realize that a compassionate society has a clear mission to serve the poor and older adults, and nearly half a century ago launched a series of strategies to address their healthcare needs. The creation of Medicare, Medicaid, and CHCs represents the most notable of these federal efforts.2-6 Lisa R. Henry is associate professor and chair of the department of anthropology at the University of North Texas in Denton, Tex. Roderick S. Hooker is a retired PA. The authors have indicated no relationships to disclose relating to the content of this article. Acknowledgement: This study was made possible with a small grant from the Physician Assistant Education Association Research Institute and the American Academy of Physician Assistants. The authors are indebted to the National Association of Community Health Centers in their critique of the proposal and the Texas Association of Community Health Centers and their efforts to obtain additional funds for a more comprehensive study. Further thanks go to the graduate students and transcribers for their contributions to the project. DOI: 10.1097/01.JAA.0000438532.92138.53 Copyright © 2014 American Academy of Physician Assistants
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CHCs were created in 1965 through federal grant initiatives to provide health and social services access in poor and medically underserved communities across all 50 states, the District of Columbia, and the territories. Funding for CHCs remains a federal function, administered by the Department of Health and Human Services’ Bureau of Health Professions. Yet the decision for how care is delivered, along with medical staffing mix, is made on the local level and is not dictated by government. Physicians, PAs, and NPs have been an integral part of CHC teams since the 1970s. CHCs now have a central role in primary healthcare delivery. In 2009, the American Recovery and Reinvestment Act directed $2 billion to CHCs over 2 years. After the first year, the initiative had reached 2.1 million new patients and 1.2 million new uninsured patients. Under the Patient Protection and Affordable Care Act (ACA), CHCs are at the center of the expansion of accessible and high-value primary healthcare. The ACA includes $11 billion in dedicated funds for CHCs over 5 years, with $9.5 billion of these funds for building new CHCs and improving existing ones. A goal of the ACA is to increase funding for CHCs, so that they could serve 40 million patients by 2015. CHCs will need to add an estimated 15,000 new providers to their staffs by 2015 to meet this goal.7 CHCs have played a critical role both in caring for the uninsured and as model primary healthcare clinics in their communities.8,9 As of 2012, more than 8,000 CHCs were serving the primary healthcare needs of more than 20 million patients across the United States and territories. The mission of most CHCs includes meeting healthcare needs of low-income populations, the uninsured, those with limited English proficiency, migrant and seasonal farmworkers, individuals and families experiencing homelessness, and people living in public housing. Though smaller CHCs might provide solely primary care for their local population, larger CHCs may also offer a federally funded pharmacy, dental care, behavioral therapies, mental health and substance abuse programs, health education, specialized women’s health services, weight loss programs, and other social services such as legal aid, transportation, and case management. Because the vast majority of people served by CHCs are poor or medically disenfranchised, we undertook this study to understand the characteristics and motivations of those who work in this setting. Volume 27 • Number 1 • January 2014
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Caring for the disadvantaged: The role of physician assistants
Which healthcare workers are most likely to choose to work with underserved populations and be committed to this type of practice? Rabinowitz and colleagues identified four independent predictors among physicians of choosing to provide care to the underserved: • being a member of an underserved ethnic or minority group • having participated in the National Health Service Corps • having a strong interest in practicing in an underserved area before attending medical school • growing up in an underserved area.10 Scammon and colleagues, who analyzed data from a series of qualitative studies of family practice residency programs, found that those most likely to practice in underserved settings feel a need “to make a difference” and have a desire to return to “roots,” to serve humanity, and to experience challenge and adventure.11 Similarly, Li and colleagues found that a group of health professionals committed to working with the poor had a strong sense of service to humanity and pride in making a difference and appeared to thrive on the challenge of creatively meeting their patients’ complex needs with limited healthcare resources.12 Only a few research studies have specifically addressed the role of PAs and NPs in working with the underserved, especially in rural areas.13-19 In a study conducted in California and Washington State, Grumbach and colleagues found that PAs ranked first or second in each state in the proportion of their members who practice in rural areas.13 Further, a national study found that PAs and NPs are proportionally more likely than physicians to work with rural populations than urban populations in chronic disease encounters.14 Staton and colleagues established that patients who lived in underserved, rural populations that did not have health insurance had higher odds of visiting a PA than patients in urban areas.15 Shi and colleagues found that PAs and NPs primarily serve as physician substitutes in medically underserved areas, where they are important to containing costs and improving access to care.16 Everett and colleagues, too, found that PAs and NPs provide the complexity and level of care that physicians provide with similar outcomes; Henry and colleagues, in a systematic literature review of PAs in rural health, confirmed that PAs are well-suited for this practice setting.17,18 Finally, Huckabee discovered that, compared with other PAs, those practicing in underserved areas have a high level of “leadership servant” qualities, such as an altruistic calling, emotional healing, and wisdom.19 The ACA will affect access to primary care as it expands health services to many groups that traditionally have been underserved and uninsured. Because these changes place strains on the existing workforce, understanding organizational dynamics, clinic culture, and the role of PAs in the provision of care may contribute to healthcare work-
force policies for delivering care to disenfranchised populations.9 Our goal in undertaking this study was to aid in this process by examining the role of PAs in providing care to the medically underserved. We have singled out CHCs for this investigation because they provide primary care and their social mission is to deliver service to the poor. The specific aims of this study are to: • understand the clinic culture of CHCs and PA roles in the provision of care • gain a broader understanding of PA practice characteristics within CHCs • explore why PAs work in CHCs • understand patient perspectives of PA contributions to CHCs. METHODS We used a qualitative, ethnographic approach in this research. Quantitative research generally starts with hypotheses to drive data collection and analysis, but ethnographic research relies on inductive and interactive processes to build theories to explain the behavior and beliefs under study. The process emphasizes exploration and discovery and lets research participants direct interviews in meaningful ways that give additional understanding to the research questions. The goal is to dig deeply into the meanings people give to their behaviors, attitudes, and motivations. This type of methodology provides depth of understanding by observing and interviewing participants in their natural environment. Population and sample This study was undertaken in one state (Texas) primarily to reduce confounding variables of heterogeneous state legislation governing PAs. We visited 10 CHC sites in 2010: five in rural areas (fewer than 10,000 people) and five in urban areas (more than 100,000 people). One principal goal was to highlight the commonalities in PA practice characteristics that override variations in CHC profiles. Preparatory research identified 332 CHC delivery sites in the state, which we then stratified by provider team composition, rural/urban status, and geographic regions. Of the 332 delivery sites, 98 (or 30%) were staffed with a PA. Of the 98 CHCs staffed with a PA, 28 were in rural areas, 48 were in urban areas, and 22 were in population areas out of the scope of this research. We telephoned the CHC office manager of every other CHC in our list of 98, after stratification, and asked permission to visit the clinic and conduct research. We continued down our list in this fashion until 10 clinics confirmed participation that spanned all regions and an equal number of rural and urban clinics. Each clinic received a $200 unrestricted grant to defray the costs of taking providers away from patient care. Office managers and medical directors told clinical staff about the research study and encouraged them to participate. Overall, rates of clinical staff participation were high; PAs and NPs had a 100% participation rate across the 10 clinics (Table 1). Participation rates were also 100% in
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ORIGINAL RESEARCH TABLE 1.
Participation rate of clinical staff
Type of clinician
Total number across clinics
Number who participated in study
PA
11
11
MD/DO
15
10
4
4
RN/LVN
20
16
Medical assistant
14
10
Total
64
51
NP
small rural clinics. No clinicians declined participation if we requested an interview. In large, urban clinics, we did not request interviews with all physicians, nurses, or medical assistants. Data collection A medical anthropologist with a background in health services delivery and health workforce studies led the study team. Specific data collection techniques for this project included semistructured interviews, observations of the general operations of the clinic without entering the examination rooms, and patient questionnaires. The University of North Texas Institutional Review Board approved this project in 2010. We conducted semistructured interviews of the CHCs’ clinical staff (medical and support staff), including PAs, MDs, and doctors of osteopathy (DOs), NPs, nurses, and medical assistants to understand the general CHC culture—that is, attitudes, beliefs, and behaviors—and the role and contributions of PAs, relying on open-ended questions and a conversational style. The data were recorded, transcribed, and cross-analyzed for common themes across all CHCs. We removed all personal identifications. We then combined data from the semistructured interviews with our observations of clinic operations. The 160 hours of recorded observations not only provided insight into how the clinics operate but how the clinical staff interacts with each other and builds rapport. TABLE 2.
Study participants: Urban vs. rural CHCs
Participant type
Rural CHC participants
Urban CHC Total participants participants
PA
5
6
11
MD/DO
4
6
10
NP
2
2
4
11
5
16
3
7
10
Patient
63
62
125
Total
88
88
176
RN/LVN Medical assistant
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To collect patient data, we asked patients to rate (on a scale from 1 to 5) how well PAs performed various functions. Some patients filled out this written survey on their own. Others were guided through the survey orally. We followed these questions with more open-ended queries to elicit how the PA was perceived to contribute to the patient’s treatment and clinic experience. We also collected demographic characteristics of the surveyed patients, including income, education, marital status, gender, ethnicity, and age. We recruited participants from a convenience sample of CHC patients who had at least one clinical visit with the PA on staff at the CHCs on research days. Patients received $10 for participating and we reassured them that identifying characteristics would be removed from the data. Although use of an incentive in survey research is controversial, we decided on this approach after discussion with those experienced in this field, in part because survey participation is known to be quite low in impoverished areas. Patient participants totaled 125, with 63 in rural CHCs and 62 in urban clinics. Of the 51 clinician study participants, PAs, MDs/DOs, and NPs were about equally represented in urban and rural clinics; registered nurses (RNs) and licensed vocational nurses (LVNs, the Texas equivalent of LPN) were primarily in rural settings; and medical assistants mostly in urban CHCs (Table 2). RESULTS Clinical staff characteristics The clinical staff was 78% female, with a mean age of 40 years. Most PAs had been nationally certified for more than 10 years (Figure 1). PAs had been 3.25 years in the current clinic (range, 7 months to 10 years) (Figure 2). Patient characteristics Patients visited the clinic for acute and urgent care (n=44), chronic care (n=22), preventive care (n=21), and follow-up visits (n=18). Twenty patients did not complete this question. Most urgent and acute complaints were for upper respiratory infections or injuries. Chronic care issues included diabetes, hypertension, high cholesterol, and asthma. Most preventive visits were checkups and well woman and well baby examinations. Return visits were for laboratory and imaging procedures or to obtain results. Most patients (84%) reported a household income of less than $25,000 in 2010. Payment for healthcare was predominantly through Medicaid, Medicare, or out-of-pocket (self-pay). A high proportion of patients (61%) were Hispanic, reflecting the predominance of this ethnicity in the state. A plurality of patients (47%) were married; 27% were single, and 26% were divorced, widowed, or separated. Twenty-six percent had less than a high school education, 29% had completed high school or obtained a general equivalency diploma, 11% had vocational training, 19% had taken some college classes, and 15% had earned a degree (ranging from associate’s to doctoral degrees). Seventy-three percent of the patients were women. Ages Volume 27 • Number 1 • January 2014
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Caring for the disadvantaged: The role of physician assistants
ranged from 18 to 75 with fairly equal distribution through the age-groups. CHC models and clinic culture Nine of the 10 clinics used PAs in a similar capacity as physicians: as clinicians with their own panel of patients. PAs maintained their own patient schedule, and patients asked to see a specific provider, be it physician, PA, or NP. Although PAs consulted with physicians on complex cases, they reported that they rarely transferred patients to the physician for follow-up care. In terms of patient preference, some patients with insurance reported they returned to the clinic out of preference for the provider. Most of the staff in the nine CHCs that practiced this broad-based model agreed that patient preference for a particular provider was consistent with desired continuity of care. Although nine of the CHCs had many similarities, one followed a different model, using PAs for same-day appointments; PAs essentially worked triage and acute care. Because of capacity limitations, PAs at this limited-model CHC followed the patients until an appointment could be made with a physician, generally within 1 to 6 months. Once assigned to a physician, the patient could not return to see the PA. The PAs at this limited-model CHC felt that patients lacked continuity of care, and patients there were less pleased with the care they received than were patients at the broad-based CHCs. The overall clinic culture also differed between these two CHC models. In the nine clinics where PAs saw their own patient load, the staff described collegial working relationships. These clinics follow a collaborative team-based strategy in which PAs pose questions to physicians on complicated cases and physicians are available to answer PAs’ questions. Physicians reported that they seek out the PAs about cases as well. But in the CHC that limited PAs to triage and acute care, clinician interviews did not give rise to spontaneous or unprompted discussion of teamwork and collaboration as they did in the other nine clinics. Physicians in the CHC that limited PA practice thought that PAs should be allowed to take on patients when triage was slow to offset physicians’ heavy patient load, but policy prohibited it. Regarding physician supervision, all PAs in all 10 clinics felt they had adequate time with their supervising physician and that the physicians were responsive to PAs if consultation was needed. We did not identify any tension in relationships between physicians and PAs nor did we see any tensions between PAs and NPs or between physicians and NPs in clinics that staff both. Of the 15 physicians interviewed, only two volunteered concerns about use of PAs. Their concerns centered on the liability of a PA medical error, creating more supervisory work for the physician and the potential for damaging the physician’s reputation. According to clinical staff in all CHCs, providers’ relationships with patients were viewed as “trusting,” meaning that the patients believed the providers were providing care in the patients’ best interest. The most detailed and
8 7 6 5 4 3 2 1 0
< 5 years
5-10 years
> 10 years
FIGURE 1. PA years of certification
seemingly candid comments about provider/patient relationships came from nurses and medical assistants. They noted that all providers worked hard to identify treatments the patients could afford and to identify specialists willing to accept the referral. For their part, patients preferred to see their own providers, whether physicians or PAs. One exception to this pattern was at a CHC in a large urban area adjacent to a major public hospital, where many patients have drug-seeking behavior. The support staff there noted that these patients are perhaps more adversarial than patients at other CHCs, particularly when they fail to obtain sought-after medications, and appeared indifferent about the particular provider they saw as long as they obtained their medications. Another exception was the limited-model CHC where PAs worked triage instead of their own patient panel. Although patients reported liking the PAs, they did not have the opportunity to build relationships with them. Nor did these patients have the opportunity to express preference for a provider (PA, NP, or physician). They were assigned to a physician if they needed long-term care at the clinic. Availability of services in CHCs Most clinical staff had positive comments about the availability of services. They volunteered comments about the comprehensiveness of care and sometimes said that patients received better primary care at the CHC than at private practices. Eight of the 10 centers have some specialty care, including dentistry, women’s health, pediatrics, pharmacy, drug cessation programs, weight loss programs, behavioral programs, cardiovascular programs, and other social services, such as legal and transportation. The clinical staff contended that the PAs “bend over backwards” to provide patients with every needed eligible service. PAs also worked to identify specialists willing to accept patients and treat them pro bono. Overall, the clinical and support staff of the CHCs appeared to care about patients and to take pride in serving them well. All of the PAs noted that their patients
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frequently tell them how thankful and grateful they are for their care, for being educated about their health condition, and for referrals to specialists. Anticipated CHC staffing Although most comments about the availability of services by PAs were positive, the clinical staff also had concerns about the future of CHCs. Some believed more clinics were needed, along with private practice physicians willing to accept sliding-scale payments and Medicaid/Medicare reimbursement. Many administrators reported that their CHCs were understaffed and needed more physicians and nurses. Some believed that if they could hire more physicians, they could also hire more PAs and NPs and accommodate more patients. The clinical staff also complained that PAs’ scope of practice was restricted by state legislation, and that they could achieve a broader range of services if restrictions on their roles were lifted. For example, they felt that PAs should have broader prescribing privileges and ability to refer patients to specialty services, instead of needing to clear these with a physician. A leading patient complaint was lengthy wait times between visits. PA practice characteristics Clinical staff estimate that PAs provide 85% to 90% of the range of services that physicians provide. Significantly, most CHC clinical staff (67%) perceived no difference between physicians and PAs in their scope of practice. The staff reported that patients rarely switch providers in the nine clinics where PAs provide primary care. Physicians listed some of the roles in CHCs that PAs do not have, including: • handling complicated cases, often involving chronic and progressive comorbidities • signing off on referrals, making home health visits, performing some minor surgeries, and prescribing Schedule II controlled substances for Medicaid and Medicare patients • reviewing medical records for quality of care • serving in a supervisory and mentoring role. In probing for differences between PAs and physicians, we heard that PAs are more likely to have “soft skills.” According to nurses and medical assistants, PAs have a holistic approach to patient care. Our overall impression is that when compared with physicians, PAs were seen as: • looking at the whole patient rather than the chief complaint • spending time talking with patients • providing more patient education • being flexible in management decisions • being collegial with nurses • more concerned than physicians with helping patients find social services. The vast majority of clinical staff also reported that PAs take more time with their patients than physicians (although the study did not verify this). The average length of appointment time varied between 15 and 20 minutes, depending on the case. Some acute cases took 5 to 10 minutes, and some chronic cases could take 20 minutes. One PA said 40
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5 4 3 2 1 0 < 1 year
1-3 years
4-6 years
> 6 years
FIGURE 2. PA years at current clinic
she takes every minute of the 20 minutes she is allotted per patient to check over the patient’s entire body or educate him or her on a particular issue. PAs report they initiate patient education even in the absence of questions. Because CHCs use PAs and NPs interchangeably in clinical roles, these clinical comments could be applied to NPs as well. However, the patient interview data revealed a few perceived differences between PAs and NPs: • PAs are more like physicians than NPs are because PA training is similar to physician training. • PAs are better trained, more autonomous, and have stronger clinical skills than NPs (a perception only of physicians) • Compared with PAs, NPs are more like nurses, are more empathetic to nurses, and will sometimes perform nurses’ tasks if necessary. All three types of clinicians reported that they enjoyed the openness and accessibility of patient relationships as well as the range of patients they see and help. Nearly all clinical and support staff noted that the most positive aspect of their work is the gratification they feel in being able to treat patients, especially those who are disadvantaged. All health professionals believe that they were able to have a positive effect on their patients’ lives and feel rewarded when they see their patients’ health improve. Almost all the PAs enjoy their working environments and the closeknit relationships they have with patients, physicians, nurses, and coworkers. For many clinicians, however, patients are also the number one cause of frustration in their work. Clinicians cited the high patient volume, patients who do not follow the provider’s prescriptions or recommendations, and patients’ low health literacy. PAs mentioned being frustrated by long work hours, a lack of resources, understaffing, and not having enough autonomy to complete certain tasks. Patient perspectives Patients gave PAs high ratings in response to the specific questions we asked about their Volume 27 • Number 1 • January 2014
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Caring for the disadvantaged: The role of physician assistants
experience with PAs at CHCs. TABLE 3. Patient perspectives of physician assistants With a highest possible rating Scores are rated on a scale of 1 (lowest) to 5 (highest). of 5, mean ratings were either 4.8 or 4.9 for each of the 10 Question Mean score questions we posed (Table 3). How courteous and respectful was the PA? 4.9 In answer to the open-ended questions, most respondents How well did the PA listen to your concerns and questions? 4.8 indicated that the PA was highly How well do you think the PA understood your problem? 4.8 effective, efficient, and knowlHow well did the PA explain to you what he or she was doing and why? 4.8 edgeable and seemed genuinely to care about patients. Many Did the PA use words that were easy for you to understand? 4.9 said they “loved” their PA. How satisfied are you with the amount of time the PA spent with you? 4.8 Most patients emphasized that the treatment and care the PAs How much confidence do you have in the PA’s ability or competence? 4.7 provided was helpful. Many How likely are you to recommend the PA to others? 4.8 said that the PA was an effective educator about treatments and How likely are you to schedule appointments with the PA in the future? 4.8 diagnoses and expressed appreOverall, how satisfied are you with the service that you received from the PA? 4.8 ciation for this education and considered it important. We heard only five negative patient comments; they related to are recognized for their skills and tasks that contribute to how the PA seemed too busy, could not perform the duties positive health outcomes for patients, and are trusted by a physician could, or made no attempt to make a personal clinical staff and patients. Because of regulations, PAs are connection. unable to perform a few tasks, and these limitations seem Most respondents said they chose to see the PA out of a to frustrate clinical staff. sense of loyalty. Patients expressed a connection or felt Health professionals working with the economically they had a personal history with the PA that they valued. disadvantaged are a small minority of workers. Their chalOther significant reasons patients cited for seeing the PA, lenges differ from those faced by clinicians whose patients however, were assignment to the PA by the appointment are more affluent or have adequate health insurance. desk or because the physician was unavailable. Some Disadvantaged patients often present complex social as patients mentioned that the PA was highly recommended well as medical issues; for example, identifying a specialist by friends or other providers. Only 7 patients (5.6%) cited willing to take patients pro bono or on a sliding scale is a finances as the reason they were at the clinic seeing the PA. time-consuming task that generally does not fall on a When asked what unique contributions the PAs made private practice clinician. This social challenge may be a to the clinic, most patients used words such as effective, defining characteristic of practicing in a CHC and needs considerate, personable, and genuine. Thirteen patients further exploration. noted that PAs did not seem to make unique contributions Any disadvantages of working with an economically to the clinic. Only two patients noted that PAs and NPs disadvantaged population did not seem to matter to the contribute to the clinic by being cost effective. staff, however. Indeed, it appears that PAs who work in underserved areas are personally drawn to working in this DISCUSSION environment. Yet it may be that the positive organizational This onsite assessment of PAs who are working with eco- dynamics and clinic culture of CHCs—elucidated in this nomically disadvantaged patients in CHCs reveals a prostudy—are the chief factors that help PAs thrive in CHCs. vider workforce that seems to be well-integrated with staff, Patients report high levels of satisfaction with PAs and patients, and the clinical operation. The workload seems tend to seek them out as their primary care provider. Only similar to that of physicians, with little division of labor a few patients make much distinction between PAs and in 9 of the 10 CHCs. All 10 CHCs appear highly functional, physicians. Nonetheless, a recent survey by Dill and coland almost all providers seem to be carrying a similarly leagues shows that patients are open to even greater roles large panel of patients. The PAs in this study apparently for PAs and NPs.20 are content with their roles, which is reflected in long-term PAs seem to have “soft skills” that may differ from those retention. The overlap of clinical roles seems consistent of physicians. This term has not been fully defined in the with team-based care and only in the limited-model CHC literature but has been mentioned by some observers. did any significant differences emerge in how PAs were Cohen believes that soft skills comprise problem solving, used compared with physicians. Overall, PAs appear to collaboration, cultural competence, and team leadership.21 like their coworkers, enjoy the collegiality of the workplace, Additional research is needed to understand how some JAAPA Journal of the American Academy of Physician Assistants
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ORIGINAL RESEARCH
CHCs are able to thrive and expand while others struggle to stay afloat. Although the division of labor and economy of scale are important determinants of efficiency, CHC research has not addressed the dynamics provided by the collective effort of a team to effect change. Job satisfaction, managing multiple chronic conditions, team-based care models, subspecialist referral, and increasing demand are some of the issues that CHCs confront. Policy implications Most analyses show that the projected number and distribution of physicians will be inadequate to meet healthcare demands in this decade.22,23 The growth and aging of the population, chronic diseases, increasing visits per capita, and new technology will not keep pace with the demand for services.22 Most workforce analysts believe that as CHCs expand they will rely on PAs and NPs more than ever. This review of one state’s CHC experience suggests that PA use may be limited by regulation that could be more expansive and permissive. PAs may prescribe on their own signature in many states, and the liability is considered low.24 Expanding full prescribing authority in all states would improve efficiency in workflow. Also, the “incident to” clause in Medicare and Medicaid reimbursement discounts the rate to 85% of the prevailing physician fee, a clause that seems outdated and inadequate for compensation of high-value services. Full reimbursement would permit more efficiency in meeting patient needs and adequately remunerating providers for services rendered. LIMITATIONS Like all qualitative, ethnographic research, this study was exploratory and emphasizes discovery. Our findings can be used as a foundation for additional quantitative research. Though our goal was to study PAs, we included NPs in the research on clinic culture if PAs and NPs were employed in the same clinic. We did so because well into the investigation we confirmed that PAs and NPs have interchangeable roles at CHCs. Confining our study to Texas also could be considered a study limitation. We selected these CHCs because they are as representative as possible of CHCs in North America, but also are distinguishable, geographically diverse, and culturally different. CONCLUSION CHCs, developed as a way to help those who remained disenfranchised after Medicare and Medicaid were enacted, brought in PAs as a workforce innovation.25 Delivering healthcare to the medically underserved and economically disadvantaged is a role that PAs have taken on in full partnership with physicians, nurses, and other health professionals. This ethnographic research showed that multidisciplinary primary care is performed well in CHCs by a cohesive body of clinicians and staff who believe in the work they do and function as a team. JAAPA 42
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