Bryan Walker has served as a clinical research PA in two very different environments. Early in his career, he accepted a job as a clinical PA at a general neurology practice in Maryland. When he started at the practice, the practice did not participate in any clinical trials. Through Bryan’s initiative, his practice began to serve as a site for multiple sclerosis (MS) clinical trials. The doctors with whom Bryan worked were pleasantly surprised at the benefits this participation brought to their practice. The sponsors of the trials paid the practice for recruiting patients and enrolling them in the trial. Patients at the practice were delighted by the opportunity to be included in cutting-edge research without having to travel to the large academic medical center in the next city. Because most MS clinical trials compare new medications with existing medications that are known to be effective, no patients get placebo. Patients who have financial limitations were appreciative of the opportunity to receive medications at no cost even if only for the duration of the trial.

Participating with clinical trials also brought benefits to Bryan. To accurately collect data, the studies required that all investigators and subinvestigators become certified in administration of common outcome measures such as the Expanded Disability Status Scale. Obtaining these certifications has increased Bryan’s marketability as a research-oriented PA and allowed his practice to be eligible to become a clinical site for even more clinical trials.

Currently, Bryan practices neurology and conducts clinical research at Duke University Hospital in Durham, North Carolina. There he practices clinically about for approximately 70% of his time and works on administrative and research tasks for about 30% of his time. One of his current studies is a multidisciplinary translational research project evaluating the relationship between cerebral volume loss in MS patients and cognitive loss measured at the clinical level. This trial involves radiologists, neurologists, physical therapists, and biostatisticians. The goal is to better correlate magnetic resonance imaging findings with clinical findings to assist clinicians in accurately assessing treatment effects and developing prognoses for patients. Bryan identifies patients for potential involvement in the trial, consents them for inclusion in the study, performs detailed history, conducts standardized physical examinations, and works with the other investigators on protocol development and data analysis.

Bryan enjoys several aspects of his role as a clinical research PA. He loves the prospect of helping to generate new therapeutic options for patients with MS. Although vast improvements have been made in MS care in the past 15 years, there are still patients for whom the existing medications are less than optimal. Enrolling patients in clinical trials sometimes enables him to get care for patients that they would not otherwise receive because of insurance or financial limitations. Investigators have an ethical responsibility to provide the very best care for patients in studies. Sometimes this means that study patients are eligible to receive other services, such as lower cost care by other specialties within the Duke system.

Participating in research has also given Bryan more insight into the skills and interests of other types of health professionals. He has learned more about what a pharmacist, a physical therapist, a social worker, or an occupational therapist can bring to the team. He has learned that he does not have to do everything for the patient himself and that patients are often better served by referral to another type of health professional. Finally, Bryan reports that he enjoys being a researcher because it keeps him intellectually engaged. The research work refreshes his passion for clinical work, and his clinical work refreshes his passion for research.

Bryan says the main drawback to his role as a research PA is “paperwork, paperwork, paperwork.” The forms that need to be completed for research patients are far more detailed than those required for clinical care, and completing them can be mind numbing sometimes. Performing research is very time consuming, and as with patient care, he is not always assured of getting out of work right on time.

Bryan’s words of wisdom for those considering initiating involvement in research are “Just do it. You will never regret it.” He points out that there are many PAs, doctors, and PhDs who are willing to mentor those who are interested in research. Bryan does not hold an MPH or a PhD; he has been trained for his work on the job. He is quick to point out that he, not the doctor, started his practice’s involvement in clinical research at his private practice in Maryland and that PAs are ideally suited for being both clinicians and clinical researchers because of the combination of their medical training and their training in team-based care of the patient.

Stephanie Figueroa has practiced emergency medicine at the Johns Hopkins Hospital, a large inner-city hospital in Baltimore, Maryland, for nearly 15 years. She serves as the lead PA and assistant director of the observation unit within the emergency department (ED). Stephanie recently had the opportunity to complete a fellowship within the Leadership Academy of the Johns Hopkins Armstrong Institute for Patient Safety and Quality. While working with the Armstrong Institute, she developed and implemented a project to improve the way care is delivered to patients with sickle cell disease who come to the ED for their care. Her project was a classic implementation science project in that she was given no extra financial or clinical resources with which to work. She had to develop a new approach to delivering better quality care more efficiently without extra nursing or provider resources.

Previously, patients who came to the ED at Hopkins may have been seen by a number of different providers who, in the chaos of the ED, would provide inconsistent care. Some doctors and PAs would give the patients large doses of parenteral opiates, and others would simply give one does of oral opiates and discharge the patient. Nurses varied in their willingness to provide opiate pain control to patients who did not yet have a bed assignment in the ED because of assessment requirements regarding narcotic administration that were challenging to meet while patients were in the waiting room. This inconsistency of treatment led to frustration among the patients and the clinical staff alike because neither group knew what to expect from the other at each visit.

Stephanie’s project aimed to limit the number of doctors, PAs, and nurses who would care for patients with sickle cell disease by assigning these patients routinely to the observation unit portion of the ED unless the patients were in need of critical care services. This first step was the cornerstone in providing more consistent care to this patient population. In addition, care plans were developed in conjunction with the hematology sickle cell team for patients who came to the ED more often than others with the disease, allowing patients and providers alike to know what the treatment delivered for a typical pain crisis would be. Alternative assessment and treatment space was designated in the observation unit where patients with sickle cell could receive a prioritized medical screening by PAs familiar with sickle cell disease. In addition, PAs would initiate appropriate pain management, allowing patients to receive opiate treatment even if there were no open beds in the main ED or the observation unit. There, nurses could begin to provide narcotic pain medication in a supervised setting while the patient was waiting for a bed to become available. The goal was for patients to receive their first dose of pain medication, after assessment by a PA or doctor, within 90 minutes of arrival to the ED. For patients who were having a particularly bad crisis, they were placed in observation in the unit, and patient-controlled analgesia (PCA) pumps were used for the first time in the ED. PCAs not only remove the burden of the nurses to continually administer pain medications but they give patients the ability to receive timely doses of pain medication in a manner that is safer than bolus after bolus of intravenous narcotics. Standardization of the overall treatment approach to patients with sickle cell disease presenting to the ED in crisis led to consistency in care, thus decreasing the need to negotiate how pain medication would be administered across ED visits.

Removing barriers to aggressively managing patients’ pain early in their presentation to the ED has paid substantial benefits for Hopkins patients and staff. Whereas the average time from arrival to first dose of pain medication before the intervention was 2 hours and 45 minutes, now 65% of patients receive pain control within 90 minutes of arrival to the ED. Patient admissions to the hospital have also dropped from 22% of patients presenting with sickle cell pain to around 15% of presentations. These results were accomplished by analyzing the data about sickle cell patients, working with all the stakeholders to identify barriers to providing more timely care, developing new protocols and work flow plans to remove these barriers, collaborating with the hematology service to develop individualized patient care plans, and getting both nurses and providers to take ownership of the project. No one—not patients, not nurses, and not providers—wants to go back to the days before this project was implemented. Patients are getting improved care, and providers and nurses are spending much less time negotiating with patients about their care. Instead they are engaging patients in their care and help to align patients with resources provided by the hematology sickle cell care team to reduce the need for ED visits.

Stephanie has found several sources of satisfaction with becoming a quality improvement researcher. Most of all, she is thrilled with the chance to provide higher quality care for patients along with a better experience for nurses and providers. She loves the opportunity to demonstrate how PAs can be the bridge between the clinical team and the research team. She has told many high-level leaders at the Johns Hopkins medical institutions (including five hospitals) that “PAs are an untapped resource for quality improvement work” and has encouraged them to look within the group of 300+ Hopkins PAs for others who may be able to conduct projects similar to the one Stephanie headed. Stephanie has also enjoyed collaborating with other PAs, nurses, doctors, social workers, case managers, and researchers within emergency medicine and hematology to refine her project to the benefit of patients. She points to the team-based approach in which PAs are trained as key to her ability to negotiate the sometimes complex interdepartmental politics of a major U.S. medical school. Stephanie believes that getting PAs involved in quality improvement work can contribute to professional satisfaction and longevity and that PAs who do this work can really raise the profile of PAs within their institutions.

The difficulties Stephanie finds with this type of work stem predominantly from the lack of visibility of PAs within the health system and the lack of PA role models. PAs who get involved in leadership usually have to blaze their own trail. Leaders generally include doctors and nurses on committees but rarely consider including PAs. When PAs are included in committees or are recruited to be part of a quality improvement team, they are often required to do this on top of their other duties and are often not paid for the time they put into this work. Stephanie says that she “often felt like an eager little dog, nipping at their heels and trying to squeeze my way into the committee room.” Her persistence and that of other PAs at Hopkins have paid off because PAs are beginning to be included to a greater degree on health system committees and in quality improvement teams at Hopkins. Stephanie advises PAs to just keep knocking on the doors in their environments to be included in leadership opportunities and quality improvement work. She has been energized by her new roles and believes other PAs would have the same positive experience by contributing to health care quality improvement using innovation steeped in knowledge gained from the clinical practice of medicine.