James F. Cawley

Clinical prevention and population health: Curriculum framework for health professions

Abstract The Clinical Prevention and Population Health Curriculum Framework is the initial product of the Healthy People Curriculum Task Force convened by the Association of Teachers of Preventive Medicine and the Association of Academic Health Centers. The Task Force includes representatives of allopathic and osteopathic medicine, nursing and nurse practitioners, dentistry, pharmacy, and physician assistants. The Task Force aims to accomplish the Healthy People 2010 goal of increasing the prevention content of clinical health professional education. The Curriculum Framework provides a structure for organizing curriculum, monitoring curriculum, and communicating within and among professions. The Framework contains four components: evidence base for practice, clinical preventive services–health promotion, health systems and health policy, and community aspects of practice. The full Framework includes 19 domains. The title “Clinical Prevention and Population Health” has been carefully chosen to include both individual- and population-oriented prevention efforts. It is recommended that all participating clinical health professions use this title when referring to this area of curriculum. The Task Force recommends that each profession systematically determine whether appropriate items in the Curriculum Framework are included in its standardized examinations for licensure and certification and for program accreditation.

Predictive modeling the physician assistant supply: 2010-2025.

Objective. A component of health-care reform in 2010 identified physician assistants (PAs) as needed to help mitigate the expected doctor shortage. We modeled their number to predict rational estimates for workforce planners. Methods. The number of PAs in active clinical practice in 2010 formed the baseline. We used graduation rates and program expansion to project annual growth; attrition estimates offset these amounts. A simulation model incorporated historical trends, current supply, and graduation amounts. Sensitivity analyses were conducted to systematically adjust parameters in the model to determine the effects of such changes. Results. As of 2010, there were 74,476 PAs in the active workforce. The mean age was 42 years and 65% were female. There were 154 accredited educational programs; 99% had a graduating class and produced an average of 44 graduates annually (total n=6,776). With a 7% increase in graduate entry rate and a 5% annual attrition rate, the supply of clinically active PAs will grow to 93,099 in 2015, 111,004 in 2020, and 127,821 in 2025. This model holds clinically active PAs in primary care at 34%. Conclusions. The number of clinically active PAs is projected to increase by almost 72% in 15 years. Attrition rates, especially retirement patterns, are not well understood for PAs, and variation could affect future supply. While the majority of PAs are in the medical specialties and subspecialties fields, new policy steps funding PA education and promoting primary care may add more PAs in primary care than the model predicts.

Career Flexibility Of Physician Assistants And The Potential For More Primary Care

In part because of their core generalist education, physician assistants can change clinical specialties over the course of their work life. This is known as career flexibility. Using medical care providers who can adapt quickly to new opportunities could help alleviate medical workforce shortages in primary care. We studied annual surveys undertaken by the American Academy of Physician Assistants to determine how many physician assistants changed specialties and how frequently. Over four decades, 49 percent of all clinically active physician assistants changed specialties sometime in their careers. This suggests that incentives, such as educational grants, could draw more physician assistants to work in primary care. These findings suggest that an array of new incentives under health reform could draw and retain more physician assistants into primary care medicine.

Emergency medicine services: Interprofessional care trends

To understand trends in emergency medicine and interprofessional roles in delivering this care, we analyzed a 10-year period (1995 – 2004) by provider, patient characteristics, and diagnoses. The focus was on how doctors, physician assistants (PAs) and nurse practitioners (NPs) share emergency medicine visits. The National Hospital Ambulatory Medical Care Survey of over 1 billion “weighted” emergency room visits for 1995 to 2004 was analyzed. The majority of patients were female (53.2%); the mean age of all patients was 35.3 years old. By 2004, physicians were the provider of record for emergency visits at 92.6%, with PAs at 5.7% and NPs at 1.7%. Emergency visits increased for all three providers over the ten years with PA growth doubling during this same period. Medications were prescribed for three-quarters of the visits and were consistent in the mean number of prescriptions written across the three prescribers. No significant differences emerged when urban and rural settings were compared. Expansion of the roles and interprofessional care provided by NPs and PAs include increasing acceptance, clarification of legal and regulatory aspects of practice, shared roles, team approaches to shortages of fully-trained doctors, and the limitation of working hours of physician postgraduate trainees. The US forecast for emergency department visits is expected to outpace the growth of the population and the supply of emergency medicine providers. In view of an increasing emergency medical demand and a continuing shortage of physician personnel, policies are needed for workforce planning to meet the demand.

Differences in the Delivery of Health Education to Patients With Chronic Disease by Provider Type, 2005–2009

Introduction Health education provided to patients can reduce mortality and morbidity of chronic disease. Although some studies describe the provision of health education by physicians, few studies have examined how physicians, physician assistants, and nurse practitioners differ in the provision of health education. The objective of our study was to evaluate the rate of health education provision by physicians, physician assistants, and nurse practitioners/certified midwives. Methods We analyzed 5 years of data (2005–2009) from the outpatient department subset of the National Hospital Ambulatory Medical Care Survey. We abstracted data on 136,432 adult patient visits for the following chronic conditions: asthma, chronic obstructive pulmonary disease (COPD), depression, diabetes, hyperlipidemia, hypertension, ischemic heart disease, and obesity. Results Health education was not routinely provided to patients who had a chronic condition. The percentage of patients who received education on their chronic condition ranged from 13.0% (patients with COPD or asthma who were provided education on smoking cessation by nurse practitioners) to 42.2% (patients with diabetes or obesity who were provided education on exercise by physician assistants). For all conditions assessed, rates of health education were higher among physician assistants and nurse practitioners than among physicians. Conclusion Physician assistants and nurse practitioners provided health education to patients with chronic illness more regularly than did physicians, although none of the 3 types of clinicians routinely provided health education. Possible explanations include training differences, differing roles within a clinic by provider type, or increased clinical demands on physicians. More research is needed to understand the causes of these differences and potential opportunities to increase the delivery of condition-specific education to patients.

Physician assistants and Title VII support.

Federal support through Title VII, Section 747 has played an important role in promoting the use of physician assistants (PAs) in primary care and in the growth and institutionalization of PA educational programs in the United States. Federal workforce policy approaches include PAs in strategies to (1) increase the supply of generalist providers, (2) better balance the distribution of providers to rural and medically underserved areas, and (3) improve the diversity of the health workforce. Evidence from several decades shows that, likely because of Title VII program incentives, PAs have met expectations in terms of practicing in primary care specialties and serving in rural and medically underserved areas. Yet, increasingly, market forces and decreasing federal support for Title VII are affecting these trends, with PAs, like physicians, being drawn to specialty practices.There is considerable use of PAs in all practice settings in U.S. medicine. For several decades, PA training programs have demonstrated that they are efficient means of preparing clinicians who provide considerable benefit to society in return for a modest public investment. At the present time, when the climate seems not to favor public subsidy of health professions education, it may be wise for policy makers to consider strategies that address the long-term needs of the health care workforce and the public for primary care clinicians.This article is part of a theme issue of Academic Medicine on the Title VII health professions training programs.

Physician Assistant Education: An Abbreviated History

Physician assistant educational programs began as part of a larger movement in the creation of new health professions. The educational organizations of the PA profession were fashioned by physician leaders in medical education. In developing PA programs, progressive physicians and others created innovative approaches to medical education that included decentralized education, emphasis on psychosocial components, and creative deployment approaches. The competency-based PA model employed ideas and elements that were ahead of their time in health professions education. PA education moved to a degree-based system in the 1990s. PA education was based on nontraditional models of medical education that have proved to be successful in training effective generalist clinicians.

Physician Assistants in Primary Care: Trends and Characteristics

PURPOSE Physician assistants (PAs) have made major contributions to the primary care workforce. Since the mid-1990s, however, the percentage of PAs working in primary care has declined. The purpose of this study was to identify demographic characteristics associated with PAs who practice in primary care. METHODS We obtained data from the 2009 American Academy of Physician Assistants’ Annual Census Survey and used univariate analyses, logistic regression analyses, and χ2 trend tests to assess differences in demographics (eg, age, sex, race) between primary care and non–primary care PAs. Survey respondents had graduated from PA school between 1965 and 2008. RESULTS Of 72,433 PAs surveyed, 19,608 participated (27% of all PAs eligible to practice). Incomplete questionnaires were eliminated resulting in a final sample of 18,048. One-third of PAs reported working in primary care. Female, Hispanic, and older PAs were more likely to work in primary care practice. Trend tests showed a decline in the percentage of PAs working in primary care in the sample overall (average 0.3% decrease per year; P <.0001). In the cohort of 2004-2008 graduates, however, the percentage of primary care PAs increased slightly by an average of 0.9% per year (P = .02). Nonetheless, the low response rate of the census limits the ability to generalize these findings to the total population of PAs. CONCLUSIONS Demographics associated with an increased likelihood of primary care practice among PAs appear to be similar to those of medical students who choose primary care. Knowledge of these characteristics may help efforts to increase the number of primary care PAs.

Origins of the physician assistant movement in the United States

&NA; The 1960s saw a rethinking of health care delivery in the United States. The physician assistant (PA) emerged from that reconceptualization, along with the nurse midwife (CNM) and the nurse practitioner (NP). The PA, CNM, and NP were the product of demand for greater health care access, especially for the nations poorer citizens. All three groups benefited from federal activism in health workforce policy. The PA had one characteristic not shared with the new nursing professionals: a connection in the publics mind with returning Vietnam War veterans. Several energetic trailblazersnotably eugene Stead, Richard Smith, E. Harvey Estes, and Henry Silver‐conceived and promoted their particular versions of the PA. The boosters of this new health professions movement worked through existing medical education programs and federal health care initiatives. Their efforts, sometimes informed by models of nonphysician health care abroad, received critical support from private philanthropy. Then, in 1969, the American medical Association (AMA) rather unexpectedly gave its official approval to the concept of the PA. As optimistic as the originators of the PA movement were, even they did not anticipate the critical role PAs would play in health care delivery well into the new century. US physician assistants also continue to influence medical providers in other areas of the world. This paper re‐examines the history of the physician assistant movement at the 50th anniversary of the concept. The authors use archival sources, policy analyses, interviews with principal figures, and secondary historical literature to explain the establishment of the PA movement in the 1960s and analyze its continuing influence.

Workweek restrictions and specialty-trained physician assistants: potential opportunities.

The increasing use of physician assistants (PAs) in surgical settings is part of a continuing trend of PA specialization, and many graduate medical education (GME) programs in teaching hospitals have hired PAs to augment physician housestaff duties. PAs have been shown to be effective in these roles by contributing to the continuity of care and enhancement of resident educational experiences. One strategy for educating and training specialty PAs to help augment perioperative surgical workforce needs for acute and critically ill patients is PA postgraduate training programs, which are typically offered as formal 1 year experiences following entry-level PA education and based on the GME model. Many academic health centers (AHCs) are well positioned to host such educational programs by collaborating with PA educators to develop additional surgical postgraduate training programs. We propose a model to produce an increased supply of specialty-trained PAs to serve as permanent hospital-based clinicians who could enable surgical residency training programs to meet critical resident education and operative experience needs by providing team-oriented and physician-supervised perioperative care.