Historical Perspective

The physician–PA relationship has evolved since the inception of the PA profession. The team-based model of care that exists today differs from the original concept envisioned by Dr. Eugene Stead of Duke University, who is generally credited with founding the PA profession. In an early monograph describing his vision for the PA’s role, Dr. Stead intended for PAs to be trained in laboratories and clinics to perform an array of procedures, diagnostic tests, and medical therapies. Noting that the physician would direct the activities and would be legally responsible for all acts of the PA, it was thought that PAs would provide medical care in clinics, hospital settings, patient homes, and outlying communities. Dr. Stead also discussed administrative duties for which PAs would be responsible, including the organization of “medical care units,” managing all aspects and elements of patient care, ranging from technicians and nursing staff to housekeeping and custodial personnel. Although PAs would be trained to recognize certain medical conditions such as heart failure and shock, Stead posed that PAs would not be involved in the clinical diagnosis, decision making, and treatment of medical problems.

The scope of PA practice has evolved since Stead’s early vision to include a holistic approach to medical care, spanning all aspects of patient management. The importance of the physician–PA relationship, however, has remained integral to the PA profession. Although he may not have anticipated these changes, Stead made this prescient prediction of the value of PAs to physician practice: “They will be capable of extending the arms and the brains of the physician so that he can care for more people.” This statement remains true today.

Shared Knowledge Base

The relationship between physicians and PAs begins at the educational level. Although there is wide variability in the methods of curriculum delivery among PA education programs, the content delivered is based on the medical model. Because there is little discernable difference in the content delivered in both PA and medical education, PAs and physicians possess a shared knowledge base. The basic elements of medical education include knowledge of the basic sciences and evidence-based medicine, patient interviewing and interpersonal communication skills, physical examination skills, medical ethics, critical thinking, and clinical problem-solving abilities. These elements represent the core knowledge base of physicians and PAs alike.

Many PA programs are administratively located within medical schools or academic health centers, and others are associated with hospitals, large health systems, or military medical facilities. It is common for PA students to share classes, faculty, and experiential education sites with medical students. Some programs housed within medical schools have fully integrated the PA curriculum into the medical school’s curriculum. Having both been trained in the medical model, physicians and PAs develop a similarity in medical reasoning that eventually leads them to use a consistent approach to patient care in the clinical workplace: “PAs think like doctors.”

Training side by side builds camaraderie and allows PAs and physicians to understand one another’s competence, knowledge, and skill levels. This leads to mutual trust and respect and creates the foundation of the physician–PA relationship.

Dependent Practice Versus Interdependent Practice

As the profession has matured and health care needs have evolved, so too has the way in which physicians and PAs have formulated practice styles and plans. What once was clearly a dependent practice, relying on one practitioner to supervise a single PA, thereby limiting scope of practice, has evolved to an interdependent practice, in which the PA and physician rely on each other to provide high-quality health care to a wide range of patients in all settings.

The interdependent practice of physicians and PAs over time has shown itself to be a cost-effective, dynamic, and medically sound approach to health care. This interdependent practice assures the patient of a high-level, quality health care experience in the style of the physician while helping to maintain continuity in the system. The physician benefits by being in the best position to determine that care is provided at the standard the physician seeks to provide as well as freeing up the physician to see to the most complex and critical problems. As Kimball and Rothwell have noted, regardless of the structure of their practice, if a PA determines that a patient’s condition is beyond his or her expertise, the PA will expedite referral to the physician or another specialist. In its landmark report “Crossing the Quality Chasm,” the Institute of Medicine discussed the importance of “communication among members of a team, using all the expertise and knowledge of team members, and where appropriate, sensibly extending roles to meet patient needs.” This approach clearly reflects the physician–PA team and all its attributes. This reflects all the interdependent and interconnected roles that the physician–PA team strives to achieve. Through this interdependent role, there is assurance that the PA will receive the appropriate backup when needed; this interdependence reassures the patient that his or her care is continuous, monitored, and of high quality and reassures the physician that care will be provided at the physician’s standard of care.

Communication, Coordination, and Continuity of Care

Communication is vital to a successful interdependent practice. It also requires advanced interpersonal skills and the ability to coordinate care among multiple providers and systems. Interdependent practice can improve patient care, outcomes, and satisfaction for patients and providers. Interpersonal skills, which include all of the hallmarks of professionalism (see Chapter 33 ), form the foundation of a developing working relationship with the physician and lead to a fully developed, integrated, and interdependent practice.

Without clear lines of communication, the system quickly falls apart, leading toward mistakes; misunderstandings; and at its worst, harm to the patient. Initially, it is important to develop lines of communication that will benefit the physician, the PA, and the patient. This can be done through the development of practice plans, physician delegation of workloads as defined, and regular meetings to discuss current working arrangements. This fluid and ever evolving approach allows for expansion of duties, reassignment of resources, and more clearly defined working roles and relationships leading toward expanded patient services.

In the joint policy statement from the American Academy of Family Physicians (AAFP) and the American Academy of Physician Assistants (AAPA), the associations recognize the need for a shared commitment to achieving positive working relationships. This occurs by first understanding each member’s roles and then maintains and enhances the relationship by effective communication. Nowhere is this more obvious than when the physician and PA are located at different sites. Particularly in this situation, the use of technology becomes extremely helpful to support and facilitate communication and the practice of medicine. With the movement toward electronic medical records, communication and delegation of practice will expand with easier access to patient records, as well as improvement in the continuity of care within the practice and throughout the health care system.

Continuity of care has been defined as the “process by which the patient and the physician are cooperatively involved in ongoing health care management toward the goal of high quality, cost-effective medical care.” In its joint policy statement, the AAFP says that this continuity is facilitated by the physician-led team.

With its focus on communication, coordination of medical care, and the provision of that care in a continuous model, the physician–PA relationship not only benefits the patient but also helps expand health care and its limited resources.

Delegated Scope of Practice

As medical practice has evolved over the years, tremendous change has occurred in the specific tasks to be accomplished by medical professionals, including PAs. Although scope of practice is a key section of the law and regulations in each state, generally the state delegates to physicians the authority to determine the scope of practice for PAs. This approach was reaffirmed by the Federation of State Medical Boards (FSMB), which stated: “Supervising physician should be legally responsible for the delegation of medical tasks, the performance and the acts of omissions of the physician assistant.” Although physician delegation is a “major defining characteristic of PA scope of practice,” Davis et al note, “PA scope of practice is generally defined by four determinants: PA education, experience, and preference; physician delegation; facility credentialing and privileging; and state law and regulations.” Having pointed to the role of the latter, the authors conclude: “Ultimately, the PA-physician team best determines PA scope of practice.”

Because the role of the PA in a practice is highly individualized, physicians and PAs who are working together are in the best position to define the PA’s scope of practice. They can evaluate the many factors that go into that PA’s role, including the type of practice, the setting, the acuity of the patients, the physician’s needs and preferences, and the PA’s training and experience.

Evaluating the knowledge, skills, and abilities of the PA is a key step in scope of practice delegation. The physician can observe the PA’s performance and can make sure the PA possesses the requisite clinical knowledge and accomplishes tasks and procedures in a highly competent manner. This was reaffirmed in the policy statement jointly written by the AAFP and the AAPA, which stated: “The physician evaluates the PA’s competency and performance, and together they develop a team approach based on both the PA’s and physician’s clinical skills and patient needs.” In its monograph on the physician–PA relationship written with the AAPA, the American College of Physicians (ACP) stated, “The physician has the ability to observe the PA’s competency and performance and plan for PA utilization based on the PA’s abilities, the physician’s delegatory style, and the needs of the patients seen in the practice.”

It must also be recognized that the scope of practice of the PA is not static but evolves over time. Physicians play a key role in the development of PAs by mentoring them in the clinical setting. This effort combined with that learned from formal continuing medical education programs allows PAs to gain the advanced or specialized knowledge needed for their scope of practice to grow and change and to keep up with advances in the medical profession.

Although the attention is often focused on its legal aspects, scope of practice is also a key expression of the physician–PA relationship. How much and what is delegated in the scope of practice is a measure of the level of trust and confidence placed in the PA by the physician. Scope of practice decisions also impact the effectiveness of the physician–PA team. The AAFP–AAPA joint policy statement notes: “The most effective physician-PA team practices provide optimal patient care by designing practice models where the skills and abilities of each team member are used most efficiently.”

Scope of practice is also central to optimal patient care. PAs believe that patients are best served when the physician–PA team treats patients in a consistent practice style and the socialization of PAs facilitates their adoption of the individual practice patterns of the physician. It is most important when discussing scope of practice to realize that patients seen by a PA are evaluated and cared for with a level of skill and competency similar to the manner in which a physician would treat a similarly situated patient.

Autonomous Medical Decision Making

Autonomous decision making has always been an issue for clinical providers other than physicians. In strict definition, autonomy is having the right or power to self-govern or to carry on without outside control. Although this strictly defines autonomy, it fails to recognize the unique team-based approach that the physician and PA maintain. In this model, autonomy is delegated by the physician, allowing the PA to practice medicine as trained, able to make health care decisions within the scope of practice delegated by the physician, without the need for input on these decisions unless the PA determines that the patient will be best served by physician input.

In the AAFP–AAPA joint policy statement, they use the concept of “delegated autonomy” and compare the relationship of the physician–PA practice to that of attending and resident physicians. They outline the key components of this delegated autonomy that should include clear lines of accountability as well as reciprocal responsibilities of seeking and providing supervision and consultation. This term is reflective of an earlier term used by Eugene Schneller, a medical sociologist, who observed PA practice in the early years of the profession. Schneller coined the term “negotiated performance autonomy” for this evolutionary process that leads to increased delegation of scope of practice.

Chumbler and colleagues defined “autonomy of practice” for PAs as “the extent to which PAs can determine independently the range of tasks they will perform.” The authors further defined the concept of autonomy of practice as having two components: clinical decision making and prescriptive authority. As the profession has matured, so too has the level of autonomy within delegated roles of the PA. As White and Davis noted, there has been a trend toward more physician-determined scope of practice as delegated activities have increased instead of trying to list in state and federal law all activities performed by a PA. This allows for the original premise of the physician–PA team-based practice to function as originally designed, with “delegated autonomy” determined by the physician’s comfort and the PA’s demonstrated competence. This trend may be due to physicians being trained alongside of PAs, understanding the PA role better, or the expansion of state and federal laws, as well as the movement of PAs into areas of medicine outside of the traditional primary care scope of training. It is anticipated that these roles will continue to evolve over time as practice plans and laws evolve and the profession continues to mature. This has been noted and borne out in monograph statements from the AAFP and ACP and in works by White and Davis and Chumbler et al.