Introduction
Ever since the physician assistant (PA) profession was developed, one of its defining features has been the relationship between PAs and physicians. When physicians created the PA profession, they envisioned PAs practicing medicine with physician delegation and supervision. Throughout the profession’s more than 50-year history, PAs have consistently embraced the concept of team-based health care. PAs believe that the physician–PA team provides the framework of practice to ensure the delivery of high-quality health care.
The relationship was first described 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 describes an intention 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, Stead writes that PAs would provide medical care in clinics, hospital settings, patient homes, and outlying communities. Dr. Stead also discusses administrative duties for which PAs would be responsible, including the organization of “medical care units,” which would manage all the 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 poses that PAs would not be involved in the clinical diagnosis, decision making, or treatment of medical problems. Nevertheless, as health care delivery has changed and the PA profession has demonstrated its ability to serve patients effectively, that capacity has evolved. Many of the diagnostic and therapeutic responsibilities central to the role and scope of practice of today’s PAs were not part of Stead’s original vision for the 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.”
The legal, employment, clinical oversight, and collegial dimensions of the relationship between PAs and physicians have always been complex and multifaceted. Over time, those dimensions have been variable given the practice setting, the practice specialty, the employer, and the state in which the PA practiced. Currently, those relationship dimensions are being affected by a variety of forces.
As significant portions of health care delivery have consolidated under the umbrellas of larger health systems, the employment relationship between physicians and PAs has changed. Where PAs were once more commonly employed by solo physicians or groups of private practice physicians in the past, now both PAs and physicians alike are more likely to be employed by health systems. As the decision-making role of health systems regarding team delivery models increases, physicians who may ultimately be teamed with a PA may not hold the final responsibility for hiring decisions.
Another force influencing the PA–physician practice has been the increasing expectations for the efficiency and effectiveness of the team. In addition to patient care responsibilities, PAs and physicians have added responsibilities and demands on their time that affect the function of the team. Additional expectations have been driven by the introduction of the electronic medical record (EMR). Precertification conversations with insurers and other tasks resulting from the patient encounter demand increased clinician attention. Physicians have less time for the roles they have traditionally played in the clinical oversight dimension of team practice: mentoring PA colleagues, responding when called upon to provide guidance with challenging patients, and reviewing charts or discussing cases. Changes have also been seen in the legal dimension. Because physicians may no longer be responsible for hiring decisions and multiple physicians may share the responsibility for the clinical oversight of PAs, the rationale for linking the liability for services delivered by a PA to an individual physician may no longer be logical.
When considering these changes, the American College of Physicians (ACP) expanded on that theme, stating: “Flexibility in federal and state regulation [is encouraged] so that each medical practice determines appropriate clinical roles within the medical team, physician-to-PA ratios, and supervision processes, enabling each clinician to work to the fullest extent of his or her license and expertise.”
Although the PA profession’s commitment to working in team practice is unwavering, there is an increasing recognition that the dimensions of the physician–PA team practice must continue to evolve to reflect the changing practice of medicine. Understanding the proposals for how to further evolve requires one to understand the elements of the PA–physician relationship and how it has changed over time ( Box 2.1 ).
The practice acts of PAs in most states require either a collaborative relationship with a physician or some level of physician supervision. Wide variability exists in the type of physician–PA interaction mandated by law. Supervision can be divided into three general categories: prospective, concurrent, and retrospective. Although perhaps not using these specific terms, each state’s laws contain elements of one or more of the following categories, which have been used historically to describe the working relationship between physicians and PAs.
Prospective:
Agreements, both formal and informal, made between the physician and PA at the time of employment that delineate the duties and responsibilities of both parties constitute the prospective element of collaboration. These agreements are based on the anticipated scope of PA practice and assume the likely or expected scenarios and patient population that will be managed by the PA. Formal agreements are required in many states; however, in all situations, an informal discussion about both parties’ expectations should occur early in the PA’s employment. Many states require written agreements, known as delegation agreements or practice agreements.
Concurrent:
The oversight and availability of the physician that occur on an ongoing, daily basis form the bulk of the element of concurrent collaboration. Medicare’s description of the three levels of physician supervision for diagnostic tests provides a reasonable framework for considering the availability of the physician to the PA envisioned. General supervision means that the physician must be available to the PA at all times. Direct supervision means that the physician must be physically present in the building. Personal supervision is the most restrictive form of concurrent supervision, requiring the physician to be present in the room when the PA provides care. Because of the delegatory nature of the physician–PA team, this type of supervision is rarely necessary or required.
Retrospective:
The process of evaluating the performance, clinical activities, and quality of care provided by the PA makes up the final aspect of collaboration, the retrospective element. The evaluation may take place in person, electronically, or by telephone. It involves the periodic review of patient charts, prescriptions, and orders written by the PA and often includes case discussions. The timing, frequency, and magnitude of review are dictated by the state and/or by the team.
The historic physician assistant–physician relationship
PAs are authorized to practice medicine in all 50 states, the District of Columbia, and all US territories. Although the vast majority of state laws mandate physician supervision or collaboration as a part of PA practice, changes to the definition and degree of supervision have occurred. As the need for increased efficiency and effectiveness of health care delivery has become more and more evident and the capabilities of PAs have been demonstrated, the call for changes to the state law has become more compelling.
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 formulate practice styles and plans. What once was clearly a dependent practice, relying on one practitioner to supervise a single PA, thereby limiting the scope of practice, has evolved into an interdependent practice, in which PAs and physicians 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. The model also presumes that the physician will see the most complex and critical problems. Through this interdependent role, there is also assurance that the PA will receive the appropriate support when needed. This interdependent practice assures the patient of a high-level, quality health care experience while helping to maintain continuity in the system.
A key assumption in interdependent practices is that PAs will know the limits of their expertise. As Kimball and Rothwell have noted, regardless of the structure of the practice, if a PA determines that a patient’s condition is beyond his or her expertise, the PA will expedite a referral to the physician or another specialist. This also presumes that systems will be in place to assure effective communication between the PA and physician. In the landmark report “Crossing the Quality Chasm,” the Institute of Medicine discusses 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 reflects all the interdependent and interconnected roles that the physician–PA team strives to achieve.
Delegated scope of practice
With the evolution of the medical practice, tremendous changes have occurred in the specific tasks to be accomplished by medical professionals, including PAs. The delegation of appropriate tasks is outlined in the scope of practice section of the laws and regulations in each state. As states adopted laws allowing PAs to practice, the language adopted generally delegated the authority to determine the scope of practice for PAs to physicians. Historically, physician delegation has been a “major defining characteristic of PA scope of practice.” It must be recognized, however, that the scope of practice of the PA is not static but evolves over time. Unfortunately, the existing language for scope of practice in many states has not changed over the years, often depending on a centralized state role in task delineation. Such a system makes it difficult for health care providers and health systems to adjust to needed changes in health care delivery. 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 within each practice is highly individualized, physicians and PAs who are working together are uniquely qualified to define the PA’s scope of practice. The team can evaluate the many factors that contribute to 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 has been relied on to observe the PA’s performance and to make sure the PA possesses the requisite clinical knowledge and can accomplish tasks and procedures in a highly competent manner. This was reaffirmed in the policy statement jointly written by the American Academy of Family Physicians (AAFP) and the American Academy of Physician Assistants (AAPA), which states: “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 ACP states, “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.”
Physicians have also played a key role in the development of PAs by mentoring them in the clinical setting. This effort, combined with the knowledge and skills learned from formal continuing medical education programs, allows PAs to gain the advanced or specialized knowledge needed for their scope of practice and to grow and change to stay abreast of advances in the medical profession.
Scope of practice is a key expression of the physician–PA team model. How much and what is delegated in the scope of practice is a measure of the level of trust and confidence placed in the abilities of each team member. 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.”
Physician supervision: Legal basis for physician assistant practice
A central theme of the relationship between a physician and a PA is the recognition that the physician is the more comprehensively trained member of the team and therefore holds terminal responsibility for ensuring that all members of the team adhere to accepted standards of care. Under the original PA–physician model, the physician assumed legal liability and professional responsibility for all of the medical actions of the PA. With the changes in the health care environment and the movement toward Optimal Team Practice (OTP), this paradigm is shifting and may no longer be accurate.
Even when state law declares the physician is ultimately responsible for the acts of the PA, the responsibility to ensure that PAs practice in accordance with ethical, legal, and medical standards is shared and reciprocal. It is the responsibility of the PA to seek advice and consultation when indicated. PAs are often credited with the strength of “knowing their limits” and understanding when physician input should be solicited. It is incumbent upon physician–PA teams to clearly delineate the role and tasks the PA is authorized to perform.
The synergic nature of this compact is beneficial for physicians, PAs, and patients. It allows physicians to expand the capacity of their practice, knowing that patients will be cared for in accordance with their own style and preferences. It also frees the physician to focus on patients with more complex medical problems. For PAs, this arrangement ensures that a constant resource exists to provide guidance and input when difficult or complicated medical problems arise. The physician is always available to assume care of the patient if necessary. Patients can be assured that the style of practice and standard of care they receive are comparable, whether they are being cared for by the physician or the PA, and that physician involvement in their care is available at all times.
Agency relationship
A past article on scope of practice includes a reference to another key descriptor for the legal relationship between the physician and the PA, noting: “In the eyes of the law, the PA serves as the agent of the physician.” Agency is a fundamental legal concept that is relevant to situations when the PA acts on behalf of the physician. Agency has been described as the “fiduciary relation which manifests from the consent by one person to another that the other shall act on his behalf and subject to his control, and consent by the other so to act.”
Three factors must be present for an agency relationship to exist between two parties, such as between the physician and the PA. The physician consents to the relationship; the physician accrues some degree of benefits from the acts of the PA; and the physician has some degree of control of, or right to control, the PA. The “assent, benefit, and control test” can be applied even in situations when assent can be implied in the absence of express consent by the physician (e.g., when the physician is hired by the hospital or practice and supervising the PA is one of the assigned duties).
Early in the development of the profession, establishing the responsibility of the physician for the actions of the PA was a key factor in recognizing that the PA possessed the authority to establish valid patient care orders in the hospital setting. In a key article on the topic, Bissonette recounts several key attorney general opinions that point to the agency relationship in regard to patient orders. “The Attorney General in Maryland concluded, ‘It must be presumed that a properly credentialed and supervised PA issues orders with the authority delegated to him/her by a licensed physician.’ The Michigan Attorney General noted that physician delegation to the PA confers authority to the agent (PA) to do things that otherwise the physician would have to do.” A key court decision also relied on this concept to establish PA authority for order writing. The Supreme Court State of Washington held that it was the intent of the legislature to establish PAs as agents of the physician; therefore every order given by a PA is considered to be coming from the physician. , In most state laws, the PA’s authority to act is derived from the physician’s authority. Therefore PAs must be considered as “agents of the physicians rather than independent practitioners.” The question of to whom the liability runs is central to agency analysis. Thus, after an agency relationship is established, both the physician and PA are liable for the acts of the PA.
Autonomous medical decision making
Physician–PA team practice can most effectively operate if team members appropriately allocate their time and talents. “The most effective clinical teams are those that utilize the skills and abilities of each team member most efficiently.”
Autonomous decision making has always been an issue for clinical providers other than physicians. In its 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, allowing the PA to practice medicine as trained and make health care decisions within his or her scope of practice 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 with that of attending and resident physicians. They outline the key components of this delegated autonomy, which should include both clear lines of accountability and 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, meanwhile, 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 note, 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 of the 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 the result of physicians being trained alongside PAs and understanding the PA role better or may come from 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.
The key features of this unique team were recognized by the Pew Health Professions Commission in its 1998 report on the PA profession, where it pointed to the use of consultation, referral, and review of PA practice by the physician. The report concluded, “The characteristics of this relationship are also considered to be the elements of professional relationships in any well-designed health system.”
When practitioners, health care systems, and employers are aware of the unique state rules and regulations governing PAs and communication are open on both sides (employer–employee, partner–supervisor, and so on), then the physician–PA team can flourish, leading to high levels of autonomy, satisfaction, high-quality health care, and excellent patient outcomes. Successful team practice depends on all of those involved having a clear understanding of what their responsibilities will include.
Communication, coordination, and continuity of care
Communication is vital to successful team practice. Team practice 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 35 ), form the foundation of a developing working relationship with physicians and other team members and lead to a fully developed, integrated, and interdependent practice.
In the joint policy statement from the AAFP and the AAPA, the associations recognize the need for a shared commitment to achieving positive working relationships. This occurs by first by understanding each member’s roles and then maintaining and enhancing the relationship through effective communication. Nowhere is this more obvious than when physicians and PAs 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 EMRs, communication will expand with easier access to patient records; there will also be improvements 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.”
With its focus on communication, coordination of medical care, and the provision of that care in a continuous model, an effective physician–PA partnership flourishes, which not only benefits the patient but also helps to expand health care.
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 discernible difference in the content delivered in PA and medical school educations, PAs and physicians possess a shared knowledge base. The key elements of medical education include knowledge of the basic sciences and evidence-based medicine, patient interviewing and interpersonal communication abilities, physical examination skills, medical ethics, critical thinking, and clinical problem-solving abilities. These elements represent the core knowledge base of physicians and PAs alike. Having a shared knowledge base facilitates communication and coordination of care.
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 team.
Evolution of practice
As the profession has matured, the team-based model has evolved. This evolution has occurred in response to changes in health care delivery, which increased demands on clinicians for effectiveness and efficiency. It was made possible because of improved understanding of the PA role and because PAs have demonstrated their ability to provide high-quality care. Nevertheless, the pace of change in state laws and regulations has lagged behind the need for such evolution. In an effort to accelerate change, the AAPA created the Six Key Elements of a Modern PA Practice Act. The first two elements include establishing “licensure” as the regulatory term to be used and acknowledging that full prescriptive authority is essential. Four of the Six Key Elements focus attention on specific changes needed to achieve adaptability for the physician–PA team. When states use an approach that allows for customization of the health care team at the practice level, the physician–PA teams can match collaboration to the specific needs of the practice.
The first of those four key elements sets the expectation that scope of practice will be developed at the practice level. The Federation of State Medical Boards (FSMB) agrees that customization of the physician–PA relationship is key to the ability of the team to meet changing needs. The FSMB states in its document “Essentials of the Modern Medical and Osteopathic Practice Act”: “A physician assistant should be permitted to provide those medical services delegated to them by the supervising physician that are within their training and experience, form a usual component of the supervising physician’s scope of practice, and are provided pursuant to the supervising physician’s instruction.”
Another key element calls for practice-level focus on adaptable collaboration requirements. 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.”
The last two key elements seek to remove onerous restrictions that may limit the ability of practices to effectively use PAs. They involve removing the restriction on the ratio of PAs to physicians and ending blanket requirements for chart co-signatures. The co-signature requirement is still included in a number of state laws and it has proven to be particularly burdensome. Such co-signature requirements result in teams delivering less efficient care.
Implications of optimal team practice on the physician assistant–physician relationship
As outlined in Chapter 5 , the 2017 AAPA House of Delegates adopted a resolution entitled Optimal Team Practice (OTP), which called for updates in state laws to adopt four components. Support for the OTP changes was based both on demonstrated quality of care delivered by PAs and the need to address evolving marketplace forces.
At the start of the PA profession when laws were first being written, there was no track record to demonstrate that PAs provided high-quality patient care. Therefore safeguards were written into medical practice acts to assure physician oversight of PA work. Since then, research and outcomes have demonstrated that PAs provide high-quality care and patients are satisfied with that care. Today, PAs are well accepted and are being called on to practice with significant degrees of autonomy.
Health care delivery models continue to evolve, with many changes rooted in efforts to attain the Triple Aim—improving the experience of care, improving the health of populations, and reducing costs. The AAPA asserts that the Triple Aim can be effectively advanced through team practice. Nevertheless, the skills and abilities of each team member must be fully utilized. Dated state laws include many burdensome administrative activities that prevent PAs from being fully utilized. , Those administrative burdens have led to the impression that other health professionals are easier to hire and manage, putting PAs at a disadvantage.
One component of OTP will undoubtedly change the PA-physician relationship. That component states, “The degree of collaboration between the physician and the practicing PA should be determined at the practice level in accordance with the practice type and the experience and competencies of the practicing PA.” Specifically, this change will eliminate requirements that the PA and a specific physician work to establish a delegation agreement signed by that physician as a prerequisite for the PA to practice. This change affects the PA-physician relationship in a number of other ways, including agency and reporting relationships. Physicians will not be required to assume responsibility and liability for PA actions unless directly involved in the care of a patient. Recall that having responsibility for PA actions was key to the legal determination that PAs were agents of the supervising physician. PAs would be able to report to or be supervised by a physician, a senior PA, or a chief PA rather than having an agreement with a specific physician.
Another effect of the OTP-led change in collaboration will be observed in the determination in scope of practice. As previously noted, most state laws presume that the supervising physician delegates their scope of practice to the PA. OTP presumes that processes will be put in place for PAs to establish their own personal scope of practice and that PAs will limit their own scope of practice to those activities and procedures for which they are adequately prepared through training and experience. The effort to bring all state and federal laws and regulations into compliance with OTP has been described as “ambitious” and is likely to take many years to fully implement. It is also noted that the success of the OTP effort depends on the PA profession’s ability to gain support from other health professions.
The yet-to-be-defined outcomes of one element of OTP relate to the assurance of quality of care. Patient care outcomes for care delivered by PAs have, to date, been measured with care being delivered in the current model. No data exist that measure outcomes for care delivered in the proposed OTP model. The PA’s retrospective case review and discussion with the supervising physician have provided the framework to assure the delivery of high-quality health care.
PAs must be involved in the state level conversations that will occur with regard to OTP implementation. They must also monitor how state laws evolve so that legal obligations to practice are met.
Practice ownership and reimbursement
The patient-centered medical home is but one of many changes in health care delivery that has occurred since the founding of the PA profession.
In an effort to meet patient needs, in certain situations PAs have assumed full or part ownership or become shareholders of a professional corporation. A key requirement to become a shareholder in a professional corporation is for one to be licensed or otherwise legally authorized to provide the services the corporation offers. Thus, when physicians are not willing or able to step forward to maintain the professional corporations under which the practice is established, the PA can step in because he or she possesses the legal authorization. PA involvement in the business of practice ownership has occurred through outright PA ownership of practices through purchase, by establishing corporations to own practices, and by creating practice arrangements. Even Medicare policies and most state laws now recognize that employment and supervision are separate and unrelated aspects of medical practice. In April 2002, the Medicare program adopted rules that allow PAs to have an ownership interest in an approved Medicare corporation that is eligible to bill the Medicare program.
Summary
Ideal physician–PA partnerships use team-based concepts to maximize the efficiency and effectiveness of the team as a whole, with the ultimate goal of excellent patient outcomes. The role of PAs within the team should optimize the use of their training and skills and allow for appropriate autonomy to practice medicine to the highest extent of their abilities. Future changes to physician–PA team practice should ensure that the team remains focused on providing excellence in promoting patient health and providing patient care based on the needs of the population served by the practice.
