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Physician Assistants in USA
Associate ProfessorDivision of CV Surgery Severance Cardiovascular Hospital Yonsei University College of Medicine, Seoul, Korea
Taek Yeon Lee, MD, PhD
The author has no financial
relationships to disclose
The author has no financial
relationships to disclose
Past – History
Present – Definition, Members, Salary, Education, Association
Future – Growth
Past – History
Present – Definition, Members, Salary, Education, Association
Future – Growth
Texas Administrative CodeTexas Administrative Code
Title 22, Part 9
TEXAS MEDICAL BOARD
BOARD RULES
Chapter 185. Physician Assistants
§§ 185.1 – 185.26
Chapter 184. Surgical Assistants
§§ 184.1 – 184.26
Title 22, Part 9
TEXAS MEDICAL BOARD
BOARD RULES
Chapter 185. Physician Assistants
§§ 185.1 – 185.26
Chapter 184. Surgical Assistants
§§ 184.1 – 184.26
BackgroundBackground Shortage of medically trained personnel Shortage of medically trained personnel
17th 17th Feldshers (German:Feldscher, Russian: Фельдшер) are introduced
into Russian armies by Peter the Great in the 17th Century
Feldshers (German:Feldscher, Russian: Фельдшер) are introduced into Russian armies by Peter the Great in the 17th Century
1672-1725
1778 1778 1778, John Wall, to assist medical officers on the USS Constellation 1778, John Wall, to assist medical officers on the USS Constellation
The American Revolutionary War( 1775-1783)
1650-19001650-1900 Officiers de Sante (1803-1892) Officiers de Sante (1803-1892)
The Napoleonic War(1803-1815)
1900- 19601900- 1960 1925 Mts in Kentucky 1940 Alaska, Eskimos and other native Americans Dr. Amos N. Johnson employs
Henry B. Treadwell in Garland, NC 1942 Dr. EA Stead - fast track to educate physicians at Emory University
for military service during WW II
1925 Mts in Kentucky 1940 Alaska, Eskimos and other native Americans Dr. Amos N. Johnson employs
Henry B. Treadwell in Garland, NC 1942 Dr. EA Stead - fast track to educate physicians at Emory University
for military service during WW II
1908-1975
1908-2005
Eugene A. Stead, Jr.MD(1908-2005)
Eugene A. Stead, Jr.MD(1908-2005)
Late 1950s masters program for nurse clinicians with Thelma Ingles, a nurse
educator, had established at Duke
1965 first formal educational program for PA at Duke
National PA Day is celebrated each year on his birthday - October 6th.
Late 1950s masters program for nurse clinicians with Thelma Ingles, a nurse
educator, had established at Duke
1965 first formal educational program for PA at Duke
National PA Day is celebrated each year on his birthday - October 6th.
1966-19721966-1972 1966 PA concept on “Look”
"More than a nurse, less than a doctor“
1966 PA concept on “Look”
"More than a nurse, less than a doctor“
1966 - 19721966 - 1972
1967 Dr. John Webster Kirklin, first formal program for SA (UAB) First Class of three PAs graduate from Duke
VH. Germino, KF. Ferrell and RJ. Scheele
1968 Duke University – first of 4 national conferences American Association of Physician's Assistants (AAPA)
1967 Dr. John Webster Kirklin, first formal program for SA (UAB) First Class of three PAs graduate from Duke
VH. Germino, KF. Ferrell and RJ. Scheele
1968 Duke University – first of 4 national conferences American Association of Physician's Assistants (AAPA)
1917-2004
1966-19721966-1972 1971 American Association of Physician's Assistants (AAPA) - first official
journal
1971 American Association of Physician's Assistants (AAPA) - first official
journal
1966-19721966-1972 1972 National Board of Medical Examiners ( NBME) begins the process
of developing a certification exam.
1972 National Board of Medical Examiners ( NBME) begins the process
of developing a certification exam.
19741974
APAP Association of Physicians’ Assistant Programs
APAP Association of Physicians’ Assistant Programs
19751975
The National Commission on Certification of Physician's Assistants (NCCPA)
Registered every 2 y Recertified every 6 y
The National Commission on Certification of Physician's Assistants (NCCPA)
Registered every 2 y Recertified every 6 y
Certifying ExamCertifying Exam
1983 PANCE NCCPA's Physician Assistant National Certifying Examination
(PANCE) was redesigned to include three components:
1 .a general knowledge/core component
2. extended core component in surgery or primary care
3. a clinical skills problems component (CSPs).
1985 PANRE
1983 PANCE NCCPA's Physician Assistant National Certifying Examination
(PANCE) was redesigned to include three components:
1 .a general knowledge/core component
2. extended core component in surgery or primary care
3. a clinical skills problems component (CSPs).
1985 PANRE
20032003
Texas becomes 41st State to authorize controlled substance prescribing for PAs.
Texas becomes 41st State to authorize controlled substance prescribing for PAs.
Other CountriesOther Countries
1992 The Canadian National Forces begin training
and using PAs.
2002 Canadian, Dutch and British
1992 The Canadian National Forces begin training
and using PAs.
2002 Canadian, Dutch and British
DefinitionDefinition
PA / SA LPNs - Licensed Practical Nurses PA-C / SA-C CST - Certified Surgical Technologist CFA - Certified First Assistants CRNFAs - Certified Registered Nurse First
Assistants
PA / SA LPNs - Licensed Practical Nurses PA-C / SA-C CST - Certified Surgical Technologist CFA - Certified First Assistants CRNFAs - Certified Registered Nurse First
Assistants
PA NomenclaturePA Nomenclature Early years : ’s – physician’s assistant physician’s associate – Duke Univ.
new health practitioners, clinical or health associates, physician extenders, mid-level practitioners, and non-physician health care providers.
In the 1980's, AAPA refer to themselves as PA (physician assistants)
Physician Assistant is the current term used to describe the profession.
Early years : ’s – physician’s assistant physician’s associate – Duke Univ.
new health practitioners, clinical or health associates, physician extenders, mid-level practitioners, and non-physician health care providers.
In the 1980's, AAPA refer to themselves as PA (physician assistants)
Physician Assistant is the current term used to describe the profession.
Applying to PA ProgramsApplying to PA Programs
health care experience Bachelor’s degrees, Master’s degrees
degree college-level courses include basic sciences; math; English/writing;
some specialized science courses, such as anatomy/physiology, microbiology, physics; computer sciences; and medical terminology.
health care experience Bachelor’s degrees, Master’s degrees
degree college-level courses include basic sciences; math; English/writing;
some specialized science courses, such as anatomy/physiology, microbiology, physics; computer sciences; and medical terminology.
EducationEducation
149 education programs for PA
medical schools and centers, hospitals, colleges and universities
149 education programs for PA
medical schools and centers, hospitals, colleges and universities
PA EducationPA Education
similar to that for medical students, although shorter in duration
(medical school education averages 155w; PA 111w)
24 - 27 m part-time education ½ classroom studies, ½ clinical rotations.
similar to that for medical students, although shorter in duration
(medical school education averages 155w; PA 111w)
24 - 27 m part-time education ½ classroom studies, ½ clinical rotations.
LicensureLicensure 1. graduates of accredited PA education programs 2. pass the PANCE (Physician Assistant National Certifying
Examination)
To remain certified 100 hours of continuing medical education every 2 years must pass a recertification examination every 6 years
1. graduates of accredited PA education programs 2. pass the PANCE (Physician Assistant National Certifying
Examination)
To remain certified 100 hours of continuing medical education every 2 years must pass a recertification examination every 6 years
MembersMembers
By AAPA, US Department of Labor's Bureau of Labor Statistics 2008-2009
1993 - 26,400 PAs
1997 - 28,500 PAs
2002 - 45,000 PAs
2006 - 86,000 PAs
CRNFAs 1,621 / SA 10,000 / CFAs 1,425 / SA-Cs 948 / CSAs 805
By AAPA, US Department of Labor's Bureau of Labor Statistics 2008-2009
1993 - 26,400 PAs
1997 - 28,500 PAs
2002 - 45,000 PAs
2006 - 86,000 PAs
CRNFAs 1,621 / SA 10,000 / CFAs 1,425 / SA-Cs 948 / CSAs 805
ScopeScope
RULE §185.10 (PA)
(1) obtaining patient histories and performing physical examinations; (2) ordering and/or performing diagnostic and therapeutic procedures; (3) formulating a working diagnosis; (4) developing and implementing a treatment plan; (5) monitoring the effectiveness of therapeutic interventions; (6) assisting at surgery; (7) offering counseling and education to meet patient needs; (8) requesting, receiving, and signing for the receipt of pharmaceutical sample prescription
medications and distributing the samples to patients in a specific practice setting where the physician assistant is authorized to prescribe pharmaceutical medications and sign prescription drug orders at a site, as provided by the Medical Practice Act, Chapter 157, and its subsequent amendments, or as otherwise authorized by this Act or board rule;
(9) the signing or completion of a prescription as provided by the Medical Practice Act, Chapter 157; and
(10) making appropriate referrals.
RULE §185.10 (PA)
(1) obtaining patient histories and performing physical examinations; (2) ordering and/or performing diagnostic and therapeutic procedures; (3) formulating a working diagnosis; (4) developing and implementing a treatment plan; (5) monitoring the effectiveness of therapeutic interventions; (6) assisting at surgery; (7) offering counseling and education to meet patient needs; (8) requesting, receiving, and signing for the receipt of pharmaceutical sample prescription
medications and distributing the samples to patients in a specific practice setting where the physician assistant is authorized to prescribe pharmaceutical medications and sign prescription drug orders at a site, as provided by the Medical Practice Act, Chapter 157, and its subsequent amendments, or as otherwise authorized by this Act or board rule;
(9) the signing or completion of a prescription as provided by the Medical Practice Act, Chapter 157; and
(10) making appropriate referrals.
ScopeScope RULE §184.12 (SA)
These generally include the following tasks: aid in maintaining adequate exposure in the operating field, cutting suture materials, clamping and ligating bleeding vessels, and, in selected instances, actually performing designated parts of a procedure...
The practice of surgical assisting is limited to surgical assisting performed under the direct supervision of a physician who delegates the acts. A surgical assistant may practice in any place authorized by a delegating licensed physician, including, but not limited to a clinic, hospital, ambulatory surgical center, or other institutional setting.
RULE §184.12 (SA)
These generally include the following tasks: aid in maintaining adequate exposure in the operating field, cutting suture materials, clamping and ligating bleeding vessels, and, in selected instances, actually performing designated parts of a procedure...
The practice of surgical assisting is limited to surgical assisting performed under the direct supervision of a physician who delegates the acts. A surgical assistant may practice in any place authorized by a delegating licensed physician, including, but not limited to a clinic, hospital, ambulatory surgical center, or other institutional setting.
ScopeScope American College of Surgeons (ACS) American Medical Association (AMA)
(e) Ideally, the first assistant to the surgeon at the operating table should be a qualified surgeon or resident in an education program that is accredited by the Accreditation Council for Graduate Medical Education (ACGME) and/or the American Osteopathic Association (AOA).
The AMA recognizes that attainment of this ideal in all surgical care settings may not be practicable. In some circumstances it is necessary to utilize appropriately trained and credentialed unlicensed physicians and non-physicians to serve as first assistants to qualified surgeons (emphasis added).
American College of Surgeons (ACS) American Medical Association (AMA)
(e) Ideally, the first assistant to the surgeon at the operating table should be a qualified surgeon or resident in an education program that is accredited by the Accreditation Council for Graduate Medical Education (ACGME) and/or the American Osteopathic Association (AOA).
The AMA recognizes that attainment of this ideal in all surgical care settings may not be practicable. In some circumstances it is necessary to utilize appropriately trained and credentialed unlicensed physicians and non-physicians to serve as first assistants to qualified surgeons (emphasis added).
ScopeScope
Physician / Surgeon’s scope Direct supervision
In selected ….. May practice …. Ideally …../ Practically ….. In some circumstances, …..
Physician / Surgeon’s scope Direct supervision
In selected ….. May practice …. Ideally …../ Practically ….. In some circumstances, …..
SupervisionSupervision (a) Supervision shall be continuous, and shall require that the
delegating physician be physically present and immediately available in the operating room to personally respond to any emergency until the patient is released from the operating room and care has been transferred to another physician. Telecommunication is insufficient for supervision purposes. (§184.13. Supervision)
(a) Supervision shall be continuous, but shall not be construed as necessarily requiring the constant physical presence of the supervising physician at a place where physician assistant services are performed while the services are performed. Telecommunication shall always be available. (§185.14. Supervision)
(a) Supervision shall be continuous, and shall require that the delegating physician be physically present and immediately available in the operating room to personally respond to any emergency until the patient is released from the operating room and care has been transferred to another physician. Telecommunication is insufficient for supervision purposes. (§184.13. Supervision)
(a) Supervision shall be continuous, but shall not be construed as necessarily requiring the constant physical presence of the supervising physician at a place where physician assistant services are performed while the services are performed. Telecommunication shall always be available. (§185.14. Supervision)
SupervisionSupervision
PA (§185.14. Supervision) not constant physical presence
Telecommunication be available
SA (§184.13. Supervision) continuous, physically present and immediately available in the
operating room
Telecommunication is insufficient
PA (§185.14. Supervision) not constant physical presence
Telecommunication be available
SA (§184.13. Supervision) continuous, physically present and immediately available in the
operating room
Telecommunication is insufficient
EarningEarning May 2008
Median $81,230 ( $68,210 - $97,070 ) The lowest 10 percent ≤ $51,360 The highest 10 percent ≥ $110,240
http://www.bls.gov/oco/ocos081.htm
Median $85,710 ; median income for first-year $74,470 Income varies by specialty, practice setting, geographical location,
and years of experience. By AAPA 2008 Census Report
May 2008
Median $81,230 ( $68,210 - $97,070 ) The lowest 10 percent ≤ $51,360 The highest 10 percent ≥ $110,240
http://www.bls.gov/oco/ocos081.htm
Median $85,710 ; median income for first-year $74,470 Income varies by specialty, practice setting, geographical location,
and years of experience. By AAPA 2008 Census Report
PAs practicePAs practice 2008
family and general medicine (25.9 %) general surgery and surgical subspecialties
(25.1 %) general internal medicine and its subspecialties (15.6 percent) emergency medicine (10.5 percent) pediatrics and pediatric subspecialties (4.3 percent) dermatology (3.6 percent) occupational medicine (2.3 percent) obstetrics and gynecology (2.3 percent) and other areas of medicine.
2008
family and general medicine (25.9 %) general surgery and surgical subspecialties
(25.1 %) general internal medicine and its subspecialties (15.6 percent) emergency medicine (10.5 percent) pediatrics and pediatric subspecialties (4.3 percent) dermatology (3.6 percent) occupational medicine (2.3 percent) obstetrics and gynecology (2.3 percent) and other areas of medicine.
1981 HMO ; 50% of cost, 79% of care PAs are cost-effective and productive members of the healthcare
team
Employment of PA is expected to grow by 39 % from 2008 to 2018
1981 HMO ; 50% of cost, 79% of care PAs are cost-effective and productive members of the healthcare
team
Employment of PA is expected to grow by 39 % from 2008 to 2018
2011 ABSA Certification Examination for Surgical Assistants
2011 ABSA Certification Examination for Surgical Assistants
1. Hold a medical degree from a medical school listed in the International Medical Education Directory (IMED), documenting English proficiency.
OR
2. ABSA approved formal surgical assistant training program. And
3. ALL the following college-level courses, 1 year, English Composition or Technical Writing, Human Anatomy & Physiology 1 semester, General Biology, Microbiology, Pathophysiology, Pharmacology, Verbal Communication course
or equivalent, College Algebra
1. Hold a medical degree from a medical school listed in the International Medical Education Directory (IMED), documenting English proficiency.
OR
2. ABSA approved formal surgical assistant training program. And
3. ALL the following college-level courses, 1 year, English Composition or Technical Writing, Human Anatomy & Physiology 1 semester, General Biology, Microbiology, Pathophysiology, Pharmacology, Verbal Communication course
or equivalent, College Algebra
Controlled SubstancesControlled Substances Schedule I - high potential for abuse. Not accepted medical use Cannabis. Heroin nicomorphine (Vilan), dextromoramide (Palfium), ketobemidone (Ketalgin),
dihydromorphine (Paramorfan), piritramide (Dipidolor), diacetyldihydromorphine (Paralaudin), dipipanone (Wellconal), phenadoxone (Heptalgin) and many others.
Schedule II - accepted medical use with severe restrictions. Fentanyl Cocaine (used as a topical anesthetic),Methylphenidate (Ritalin and Concerta) & Opium, Methadone
Schedule III - a potential for abuse less than the drugs in I and II. Anabolic steroids (including prohormones such as androstenedione); Ketamine, Hydrocodone / codeine, when compounded with an NSAID (e.g. Vicoprofen, when
compounded with ibuprofen) or with acetaminophen (paracetamol) (e.g. Vicodin)
Schedule IV - low potential for abuse relative to the drugs in III. BenzodiazepinesLong-acting barbiturates such as phenobarbital;
Schedule V - low potential for abuse relative to the drugs in IV. Cough suppressants containing small amounts of codeine (e.g., promethazine+codeine); Preparations containing small amounts of opium or diphenoxylate (used to treat diarrhea); Pyrovalerone
Schedule I - high potential for abuse. Not accepted medical use Cannabis. Heroin nicomorphine (Vilan), dextromoramide (Palfium), ketobemidone (Ketalgin),
dihydromorphine (Paramorfan), piritramide (Dipidolor), diacetyldihydromorphine (Paralaudin), dipipanone (Wellconal), phenadoxone (Heptalgin) and many others.
Schedule II - accepted medical use with severe restrictions. Fentanyl Cocaine (used as a topical anesthetic),Methylphenidate (Ritalin and Concerta) & Opium, Methadone
Schedule III - a potential for abuse less than the drugs in I and II. Anabolic steroids (including prohormones such as androstenedione); Ketamine, Hydrocodone / codeine, when compounded with an NSAID (e.g. Vicoprofen, when
compounded with ibuprofen) or with acetaminophen (paracetamol) (e.g. Vicodin)
Schedule IV - low potential for abuse relative to the drugs in III. BenzodiazepinesLong-acting barbiturates such as phenobarbital;
Schedule V - low potential for abuse relative to the drugs in IV. Cough suppressants containing small amounts of codeine (e.g., promethazine+codeine); Preparations containing small amounts of opium or diphenoxylate (used to treat diarrhea); Pyrovalerone
19611961 1961 Charles L. Hudson,MD “Expansion of Medical Professional Services
with Nonprofessional Personnel” in the June 10, 1961 in JAMA.
1961 Charles L. Hudson,MD “Expansion of Medical Professional Services
with Nonprofessional Personnel” in the June 10, 1961 in JAMA.
19641964 1964 Dr. Richard A. Smith - the MEDEX (Med-icine Ex-tension) model
1964 Dr. Richard A. Smith - the MEDEX (Med-icine Ex-tension) model
1932-