Resident Work Restrictions Create Void Physician Assistants Can Fill

The value of physician assistants to hospitals has increased as dramatically as the profession. The first PAs graduated from Duke University in 1967, and now there are more than 84,000 certified PAs around the country.

I was a physician assistant leader at the time that the AMA passed a policy that limited resident hours. Prior to 2003, resident medical education was a grueling, trial by fire. Even with the limitations on resident work hours, physician medical education is still difficult psychologically and physically.

The Accreditation Council for Graduate Medical Education (ACGME), in accord with AMA policy passed by the House of Delegates in 2002 implemented new guidelines for resident work hours.

It was clear to many physician educators, and policy makers in the AMA, that for many residents and fellows, excessive work hours have a significant impact on their educational environment, the quality of care they provide to patients, and their personal well-being.

Medical training relies on comprehensive direct patient care experience and pattern recognition. Residents must see a diverse set of patients, and participate in multiple procedures to gain the knowledge and competency needed to safely practice in their specialties. Shortening the training time available reduces residents’ exposure to quality training opportunities.

Yet, the sometimes inhuman hours worked by residents in the past raised patient safety concerns, and concerns for the physical and emotional well-being of medical residents.

While the sanity and health of residents was protected, reduction in resident hours resulted in another problem - a shortage of human resources to care for inpatients at academic hospitals.

Here’s where PAs come in. Physician leaders, and the American Academy of Physician Assistants (AAPA), have looked at PAs as an excellent resource to expand the provider base caring for inpatients at academic institutions.

Physician assistants are trained in general medicine, but have increasingly specialized since the 1960s. They work in virtually every specialty and subspecialty, and have practiced in hospitals since the inception of the profession.

A study published in 2008 in the Journal of Hospital Medicine looked at this issue in an inpatient general medicine population between traditional house staff, and PA / hospitalist teams. No difference was seen in inpatient mortality, ICU transfers, readmissions, or patient satisfaction. The authors concluded that for general medicine inpatients admitted to an academic medical center, a service staffed by hospitalists and physician assistants can provide a safe alternative to house staff services, with comparable efficiency.¹

Another two-year study published in American Journal of Medical Quality in 2009 concluded that the combination of PAs and hospitalists can meet the clinical inpatient needs of a diverse inner-city population that relies on a public hospital for acute care. Two models were studied; one being the traditional house staff model, and the second a hospitalist / PA model, Most outcomes remained equivalent between the models, including adverse events, readmission rate, patient satisfaction, and quality issues related to mortality and readmissions. All-cause mortality was actually lower during the PA / hospitalist period, although this difference may have been owing to the on-site direct attending supervision.²

Another benefit of using PAs to perform inpatient care in academic institutions is the experience and continuity of care that permanent PA house staff can be expected to provide, enhancing physician residents’ educational experience.

While this is encouraging data, additional research needs to be done to look at the role of PAs in filling the void left by residents in various medical and surgical specialty inpatient services as they work less hours.

However, it’s clear that physician assistants can continue to increase access to quality, team-based and patient-focused healthcare in any clinical setting.

Find out more about Stephen Hanson and our other Practice Notes bloggers.

1 Roy CL, et al., Implementation of a Physician Assistant / Hospitalist Service in an Academic Medical Center: Impact on Efficiency and Patient Outcomes. J Hosp Med. 2008 Sep;3(5):361-8.

2 Dhuper, S, and S. Choksi, Replacing an Academic Internal Medicine Residency Program With a Physician Assistant–Hospitalist Model: A Comparative Analysis Study. Am J of Med Qual. Mar/Apr 2009 vol. 24 no. 2 132-139.