Most physician assistant (PA) students choose to study to become PAs because they want to care for patients. If they had wanted to study for a research-oriented degree, they would have applied for MS or PhD programs in biochemistry, biology, public health, or experimental psychology. Yet even though PA students have enrolled in a clinical training program, they cannot avoid the importance of research to their careers. To engage in high-quality, evidence-based patient care, PAs need to consult research daily. PAs who are interested in improving the quality of care given to patients may become part of a team that conducts new clinical research. PAs who become educators will engage in research on how to better educate students or deploy PA graduates. In short, no PA can escape research.
What is Research?
Webster’s New World Collegiate Dictionary defines research as “careful, systematic, patient study and investigation of some field of knowledge, undertaken to discover or establish facts or principles.” Research can take many forms: basic science research in the laboratory setting, survey research, clinical research, policy research, public health or epidemiological research, anthropological research, educational research, sociological or psychological research, and workforce research. Most PAs will use or perform only a few of these subtypes of research. The research PAs most commonly use and conduct are outlined in the next section.
Types of Research
Basic Science Biomedical Research
Basic science research performed at many medical schools and research universities and by pharmaceutical companies is the first building block of understanding the pathogenesis of disease, diagnostic strategies, and treatments. These studies are performed at the atomic, molecular, genetic, or cellular levels. They may also involve animal models of anatomy, physiology, genetics, pathophysiology, and treatment. Biomedical research has produced many of the tools we use in the practice of clinical medicine. However, much of what has turned out to be useful for clinicians has actually come from fields other than direct biomedical research. X-rays and magnetic resonance imaging both came from physics. Genetics originated in botany. Discovery of the Ebola virus came from a combination of epidemiology and virology. There is a growing emphasis placed on connecting basic science researchers with clinicians to move basic science discoveries “from bench to bedside” more quickly, and many funding agencies such as the National Institutes of Health are requiring investigators to collaborate more effectively to make this happen. This new approach to biomedical science is called “translational research.”
Unlike many physicians at academic medical centers, PAs traditionally have not been very involved in basic science research. Some PAs have worked in a basic science laboratory while studying at a university, but few PAs have the advanced training needed for basic science research. PAs generally choose to become PAs because they are interested in caring for people and are less interested in bench work. A few PAs have basic science PhDs and combine clinical practice and basic science research at academic medical centers, but this arrangement is fairly uncommon. More common are PAs at academic medical centers who are part of teams that engage in translational research. PAs may be involved in advising basic science teams on the clinical implications of a new basic science finding and are often involved in the clinical trials used to assess the innovation.
Research performed on human subjects with the goal of developing more effective therapies, better diagnostic tests, or better understanding of the pathophysiology of disease is called clinical research. These are the kind of studies that are often highlighted in the health section of newspapers or in online reports of “breaking health news.” Clinical trials, cohort studies, and case-control studies are just some of the types of studies included under the banner of clinical research. It is typically not difficult to convince PA students that clinical research is relevant to their practice. Every PA would like to know which chemotherapy regimen is best for stage III breast cancer. All PAs would be thrilled to see an effective vaccine for an illness that has thus far not been preventable. Practicing PAs consume clinical research each day if they are seeking to provide evidence-based care to their patients.
Although all PAs are consumers of clinical research, some PAs are also producers of clinical research. PAs who work at medical schools are often involved in the research mission of the university. Many clinical trials, cohort studies, and case-control studies employ PAs to conduct physical examinations, psychiatric interviews, neuropsychological testing, medication monitoring, observation of participants for adverse events, and performance of many other types of data collection. Doctors often appreciate the generalist background of PAs for these tasks. For example, an orthopedist conducting a clinical trial of a new type of prosthetic hip joint typically does not have much experience in managing diabetes. Yet glucose control can substantially affect wound healing rates. Having a PA on the team who can not only assess the effectiveness of the hip prosthesis but who can also monitor the patient’s glucose control expands the range of clinical skills on the research team and provides better quality care for the study patient.
Although PAs often start out in clinical research as simply the person who performs physicals, monitors laboratory results, or collects other data, some of these PAs move up to become investigators themselves. Although federal funders and pharmaceutical companies do not typically allow PAs to be principal investigators, a PA can be one of a group of investigators on the team. To be an investigator, the PA needs to make substantial contributions to the development of the research question as well as the design and evaluation of the research project. Simply collecting a large amount of data according to someone else’s protocol does not confer investigator status. PAs who become investigators often have the opportunity to collaborate with investigators from other institutions, to present their work at scientific meetings, and to publish their findings in peer-reviewed journals. Getting involved in clinical research gives PAs a chance to develop new skills, share their knowledge with others, and bring cutting-edge treatments back to their clinics to share with patients ( Case Study 12.1 ).
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.
Quality improvement or implementation science research: Implementation science is the study of methods to promote the integration of research findings and evidence into health care policy and practice . Implementation science attempts to understand the behavior of health care professionals in the application, adoption, and implementation of evidence-based clinical interventions. Implementation science seeks to help get clinicians to actually do what they know they should do. Many times, no new knowledge is needed to improve outcomes. Instead, developing new approaches that make it easier for clinicians to adhere to best practices is the key to improved patient care. For example, one of the most effective implementation science studies ever performed essentially eliminated the incidence of bloodstream infections in intensive care unit (ICU) patients by instituting standardized practices for central line insertion. Before the intervention, providers in ICUs may have believed they knew how to prevent central line infections, but the study demonstrated that knowledge was insufficient without supporting standard operating procedures designed to reinforce best practices.
Because implementation science is a relatively new discipline, the number of PAs working on these projects is still relatively small. However, PA involvement is likely to increase because PAs are ideally suited for this work. As frontline health care providers, PAs often can identify the simple changes that can have a profound effect on the delivery of clinical care. PAs have the medical training to understand the science behind the changes in implementation and are often involved in development of standard operating procedures for their units or clinics. In teaching hospitals, PAs are sometimes the only medical staff who do not rotate on and off service. Therefore, PAs can help provide and maintain the cultural and procedural changes needed to sustain the intervention for months and years. PAs can develop new procedures, train others in the new approach, and collect data on effectiveness ( Case Study 12.2 ).
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.
Health Services Research
Health services research seeks to discover how organizational structures, payment systems, health care processes, information technologies, health reimbursement policies, health care accessibility, and human factors affect the way health care is delivered. Health services researchers seek to explain the effects of the health care system on the quality, costs, and effectiveness of the care delivered within a population. Health services researchers answer questions such as, “Do copayments for diabetes medications inhibit patients from effectively controlling their diabetes?” “Does the implementation of electronic medical records decrease the number of erroneous prescriptions filled?” or “Are Medicaid patients less likely to receive psychiatric care than patients with private insurance?” Health services research is often multidisciplinary, including health policy specialists, health economists, medical sociologists, health behavior specialists, and clinicians. Health services researchers may collect original data, but increasingly, they are harnessing the power of very fast computers to analyze large federal datasets or mine electronic medical records for extremely detailed data.
Physician assistants who work in health services research nearly all have further training in epidemiology, biostatistics, economics, or statistical programming. Although they may conduct health services research with an MPH or an MBA degree, typically these researchers have obtained a PhD in economics, business, sociology, statistics, political science, or one of the disciplines of public health. PAs’ input into health services research is extremely important for enabling these teams to ask the right questions. PA practice is often poorly understood by nonclinicians, and the PA contribution to the health system can be misrepresented by well-meaning but ill-informed scientists.
Health workforce research is the study of the education, use, and distribution of health care professionals in society. It is a subset of health services research. It seeks to understand the needs for different types of health professionals across the country, the roles each health profession can play within the health system, the most effective approaches for training health professionals, and mechanisms for deploying and retaining health professionals in the area of greatest need. Workforce research seeks to answer questions such as: “What would be the impact of allowing pharmacists to prescribe?” “Can PAs provide preventive care for patients with diabetes as well as doctors?” or “How can we retain primary care PAs in rural areas?” Many PA faculty are engaged in workforce research as our profession is new, and we are still exploring the possibilities and limits of the PA profession within the U.S. health care system, as well as health systems around the world.
Physician assistant workforce research has been the primary research field in which PAs have made a mark. From the earliest days of the profession, PAs and their allies have been performing research to answer questions such as, “Is PA practice safe?” “Are patients reluctant to see a PA?” “Are doctors willing to work with PAs?” and “How can PAs be used effectively in trauma surgery?” The oft-cited statistic that “PAs can perform 85% of a doctor’s tasks” comes from a study performed in 1986 by the U.S. government with input from PAs. Unlike in many other types of research, PAs often serve as principal investigators in workforce research. They develop the study question, design the methods that will be used to collect and analyze the data, obtain human subject approval from an institutional review board (IRB), perform the analysis, and publish the data. PAs are eligible to apply for and receive grant funds for workforce research without necessarily working with an MD or PhD.
Physician assistants in workforce research sometimes collect and analyze their own data, but they often use large datasets generated by others to analyze patterns across clinical settings and geographic regions. Federal and state governments, large health insurance groups, and large health systems such as Kaiser Permanente or the Veterans Administration often collect data on patient outcomes and provider characteristics, which can be mined for information about the practices of different health professions. However, it has been a challenge to use many of these datasets to their full potential to assess PAs’ contribution to the health system because PAs and doctors work closely together and often see the same patients. This practice style, although beneficial for patients, has made it challenging for researchers to be able to attribute changes in quality of care, length of stay, or cost specifically to the use of PAs on the clinical team. Therefore, although we believe PAs to be cost effective and the dramatic increase in the number of PA positions available within the health system suggests that doctors and health systems find PAs to be cost effective, there are no large national studies that conclusively demonstrate the cost effectiveness of the PA role ( Case Study 12.3 ).