What Do Residents Need to Know?

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Emergency departments (EDs) nationwide depend on physician assistants (PAs) to assist in seeing high volumes of patients with varying complaints and complexity. In fact, approximately 10% of all PAs practice in emergency medicine (EM).1 However, many residents and new attendings know little about PA education and training, scope of practice, and approach to care, making it difficult to understand their role within a team of health care providers. Residents who go on to supervise PAs must have a solid understanding of their training, scope of practice, and value.

Do you know these 5 key things about working with PAs in the ED?

PA Education and Training

PA education and training mirrors the medical model of education. There are approximately 140 accredited PA programs in the United States. Programs typically require similar prerequisites to those of medical schools, while also requiring approximately 3 years of direct health care experience. PA programs are typically 3 academic years in length. Didactic coursework includes anatomy, physiology, microbiology, pharmacology, and behavioral science. Clinical rotations consist of more than 2,000 hours in the areas of family medicine, internal medicine, pediatrics, emergency medicine, obstetrics and gynecology, surgery, and psychiatry. Following graduation from a PA program, some PAs extend their education through a post-graduate residency or fellowship program, such as in EM. PAs are required to pass the PA National Certifying Exam and to be licensed in the state where they practice. Intense requirements to maintain certification ensure that PAs continue to practice with the most up-to-date, evidence-based medical knowledge. Maintaining certification requires completion of 100 hours of continuing medical education every 2 years. A large portion of those hours must be earned through a combination of self-assessment CME and performance improvement CME. In addition, PAs are required to complete a re-certification exam every 10 years.

EM Specialty

The Society of Emergency Medicine Physician Assistants (SEMPA), the professional organization of PAs in EM, was founded in 1990. SEMPA is a specialty organization within the American Academy of Physician Assistants (AAPA) and is represented by a liaison to the American College of Emergency Physicians (ACEP). Post-graduate PA residency programs in emergency medicine are found in as many as 14 states. Specialty certification in emergency medicine is available through the National Commission on Certification of Physician Assistants (NCCPA). If a PA chooses to obtain this specialty certification, they must demonstrate advanced experience and knowledge in EM, above and beyond that of a PA in general practice. Applicants for this certification must pass an EM-specific national exam as well as have a minimum of 3,000 hours of emergency medicine clinical experience. Evidence of competency in a number of specific EM-related skills such as invasive airway management, anesthesia, radiographic interpretation, diagnostic/therapeutic procedures, hemodynamic techniques, and advanced wound management, is also required. Recertification for this added certification must be completed every 10 years and is in addition to the general recertification process.

Scope of Practice

Within emergency medicine, PAs may work in the general, fast-track, trauma/critical care, pediatric, observation, or other specific emergency department areas. EM PAs diagnose, treat, and manage patients with a broad variety of complaints from minor conditions and injuries to complex medical and trauma related conditions. EM PAs also perform a variety of specialty appropriate procedures and interventions. The complexity of care will vary depending on the experience and training of the individual PA, as well as the relationship with the supervising EM physician. State law and hospital credentialing privileges also guide EMPA practice. In addition to clinical responsibilities, PAs may also be involved in teaching and performing administrative duties in the department.

Fiscal Benefits

PAs are cost effective staff members for EDs. Medicare, Medicaid, TriCare, and third party payers reimburse PA care at rates typically ranging from 85%-100%.2 PAs can act as additional providers caring for a small number of complex patients or increase the efficiency of care through seeing less complex patients in a quick and timely manner, while at a departmental cost less than that of an additional physician. Using PAs in triage or fast track areas can reduce overall ED lengths of stay by expediting evaluation and treatment. It has been estimated that EM PAs can see approximately 30 percent of ED patients independently, making it possible for the ED to handle a higher volume of patients.3

Teamwork Approach

The PA profession was historically founded on the concept of team practice. PAs do not seek independent practice, but rather seek to maintain a collaborative working relationship with physicians. Deeply rooted in a team approach to patient care, PAs work to have open communication with physicians and to foster a sense of camaraderie within that relationship. PAs are not competing with physicians, but rather strive to provide excellent patient care alongside physicians to ensure efficient ED throughput. As an example of that team approach, if a patient requires sedation for a procedure, the physician may initiate and monitor the sedation while the PA does the procedure. In another example, the PA may see multiple ED patients, while the physician cares for a single complicated patient with a higher level of acuity.

Conclusion

PAs are a valuable resource for an emergency department and work with their supervising physicians to care for all types of patients presenting for treatment. PAs have both a rigorous education shaped in the medical model and a recertification process that ensures they continue to practice with the most recent evidence-based medical knowledge. Some PAs undergo additional training through residency or fellowship programs, and some have worked for a certificate of additional qualification within this specialty. PAs can care for complex patients and perform complex procedures within emergency medicine, as well as treat less acute patients and relieve physician workload. PAs are often reimbursed at rates of 85-100 percent of physician billing, while costing the department less than additional physician staffing.2 The team approach allows for multiple patients to be cared for at once as well as multiple aspects of a single patient’s needs to be met in a timely manner. PAs are not competing with physicians, but rather are striving to have an open relationship with their supervising physicians to ensure that patients presenting to the ED receive the best care possible.

References

  1. American Academy of Physician Assistants. Specialty Practice: PAs in Emergency Medicine. 2008 AAPA Physician Assistant Census Report. https://www.aapa.org/workarea/downloadasset.aspx?id=622. Accessed Jan. 31, 2016.
  2. American Academy of Physician Assistants. Reimbursement issues: Third-party reimbursement for PAs. https://www.aapa.org/WorkArea/DownloadAsset.aspx?id=1256. Accessed Jan. 31, 2016.
  3. Collins M. Staffing an ED Appropriately and Efficiently. ACEP News. August 2009.
Terry E. Carlisle, PA-C

Terry E. Carlisle, PA-C

Department of Emergency Medicine, University of Missouri-Columbia, Columbia, MO
Terry E. Carlisle, PA-C

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Michelle Seithel, PA-C

Michelle Seithel, PA-C

Department of Emergency Medicine, University of Missouri-Columbia, Columbia, MO
Michelle Seithel, PA-C

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Chadd Kraus, DO, DrPH, MPH

Chadd Kraus, DO, DrPH, MPH

Former EMRA Academic Affairs Rep, Department of Emergency Medicine, University of Missouri-Columbia, Columbia, MO
Chadd Kraus, DO, DrPH, MPH

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