Using the Modern PA Practice to Improve Patient Care

PAs have always practiced medicine in teams with physicians. History and experience has shown that healthcare teams function best when decisions regarding the individual scope of practice of a PA and other clinicians is determined at the practice level.

Everyone on the healthcare team has a variety and diversity of skills, training, and ability. If implemented correctly, team-based medicine, where care delivery is headed, makes the whole outcome greater than the sum of the parts. That said, the skill level of a PA, NP, or CRNA varies like it does for every profession with the most consistent predictor being experience.

I practice on a team with a single surgeon, who also covers the county hospital and our community hospital. As a PA with 34 years of experience, six of them in specialty surgery and hospital practice, my surgeon partner relies on me as a productive and experienced team member at the community hospital caring for our substantial patient load. The California PA Practice Act, as well as the trust extended to me by my surgeon partner, means that we, as a team, can care for more patients than would be expected or feasible by a solo surgeon.

There are many examples of collaborative healthcare teams such as ours across the system, providing further evidence that teams are most efficient and effective. PAs and the American Academy of PAs (AAPA) advocate for the profession at the state and national levels, to ensure that PAs can practice to the fullest extent of their education and experience. AAPA recommends six key elements which should be part of every state PA practice act.

1. “Licensure” as the regulatory term. For a time, terms like “certification” and “registered,” were used describe the process by which the state authorizes PAs to practice. However, many state laws refer broadly to “licensed health professionals.” To ensure that PAs are included in laws such as loan repayment and natural disaster relief, “licensure” is the appropriate term to describe the process by which a state allows PAs to practice. With recent legislation that became effective this October all 50 states and the District of Columbia now use the “licensure” terminology.

2.  Full prescriptive authority. Because prescribing medications, including Schedule II-V controlled medications and legend drugs, is integral to the practice of medicine, I could not do my job as a hospital-based PA without this element. I’m fortunate to work in a state that allows this, as it helps eliminate barriers to care and improve healthcare access and treatment for California patients.

3. Scope of practice determined at the practice site.  While PAs practice medicine in collaboration with physicians, their scope of practice is determined by what is within the individual PA’s skills, education and experience. Specific lists or limits on services PAs provide lead to team inefficiencies and limit patient access to care unnecessarily. Better that each team of PAs and physicians define their relationship and the responsibilities of both parties in caring for their patients at the practice level.

4. Adaptable collaboration requirements. Many PAs practice in rural and remote locations, with a physician available via various electronic and telecommunication modalities but not necessarily onsite. In order to continue to improve the health of all patients, collaboration requirements should be adaptable to the practice environment and the experience of the practitioners. The healthcare landscape throughout the U.S. differs vastly; we must be flexible to the needs of our patients, first and foremost.

5. Chart co-signature requirements determined at the practice. Historically, this oversight activity has generally been achieved by the physician’s “co-signing” a patient’s chart within a certain time period. However, to improve patient care or safety, we must take into consideration the skills and experience level of the PA, and the unique aspects of each practice. Ideally, the decision to engage in this activity is best determined by the physician, PA, or applicable facility. 

6. Number of PAs with whom a physician may practice determined at the practice level.  The appropriate number of PAs with whom a physician collaborates should depend on several factors that are unique to each individual situation, including the training and experience of the PA(s), the nature of the practice, the complexity of the patient population, and the physician’s approach. Limits on the number of PAs stifles creativity and flexibility of the healthcare team.

State laws and regulations governing PA practice serve two main purposes: To protect the public and to define the role of PAs in the healthcare system. Clear definition is critical as we approach this new era in team-based care delivery. Since the inception of the PA profession, the way that states regulate PAs has evolved to reflect a growing body of knowledge about PA practice. It is now possible to identify the specific concepts in PA practice acts that enable PAs to practice fully and efficiently while protecting public health and safety.