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PAs and hospital medicine

May 2012

Published in the May 2012 issue of Today’s Hospitalist

AS HOSPITALIST GROUPS struggle to cope with a shortage of physicians, many are hiring midlevels. But they often face an even more daunting challenge: figuring out how to best use nonphysician providers. The task is particularly difficult because midlevels have such a wide range of skills and experience.

To get a handle on the skill sets of midlevels working with hospitalists, a group of researchers decided to go directly to the source. They asked nearly 70 physician assistants (PAs) who had been practicing for an average of four years as hospitalist PAs to describe the clinical conditions they’re comfortable managing and what type of training they feel they need to be effective.

The survey, which was conducted in 2010 by researchers from Baltimore’s John Hopkins Bayview Medical Center, was the first to assess the learning needs of PAs in hospital medicine. Results were published in the March 2012 issue of the Journal of Hospital Medicine.

The survey found that PAs are most comfortable managing diabetes and urinary tract infections, and that they’re least comfortable managing hospital-acquired pneumonia and sepsis. Those results are telling, says lead author and hospitalist Haruka Torok, MD, MSc.

“That suggests that they probably don’t have a lot of inpatient medicine experience as undergrads,” Dr. Torok says. “Their extent of inpatient medicine training is probably less than what is needed to become a hospitalist PA.”

High expectations
Researchers said that the survey underscored the fact that PA training programs stress primary care, with only “limited exposure to inpatient medicine.” After 12 months of didactic training, PAs undergo another year of clinical rotations, mainly in outpatient settings.

To specialize after training, PAs need extensive on-the-job training. Dr. Torok says that’s a problem, given the high expectations and needs of the hospitalist programs that hire them. “We expect PAs to function at the level of residents “and I’m thinking third-year medicine residents,” she says.

At her program at Johns Hopkins Bayview, those expectations are even more problematic. That’s because the group doesn’t want to assign the PAs it hires to only niche tasks like orthopedic comanagement or discharge planning.

“They do everything that pertains to patient care,” Dr. Torok says, “from seeing patients to implementing a plan with a physician’s guidance.” While PAs, especially those right out of training, typically have a much lighter load than doctors, tailoring training to individual PAs on the job is still a struggle.

“We’re technically not hiring them as trainees,” Dr. Torok says. “And we don’t have much of a formal training structure, so it’s hard for physicians to figure out PAs’ training needs.”

If Dr. Torok’s survey results are any indication, the PAs themselves are acutely aware of that training gap. Half of those responding to the survey began working in hospital medicine right out of undergraduate training. The majority said they would have welcomed additional formal training, but the reality is that very few postgraduate PA training programs in hospital medicine are available.

PA training can be so variable, Dr. Torok adds, that some academic groups have scrapped their midlevel programs and resorted to hiring only hospitalists instead. Bayview, on the other hand, plans to use Dr. Torok’s research to find out what PAs want to learn more of and then streamline their training on the job.

What PAs say they need
As part of the survey, researchers asked hospitalist PAs what kinds of training would have helped them. Heading up that list was training in palliative care, nutrition for hospitalized patients, performing consults and preventing health care-acquired infections. At the bottom of the list were caring for uninsured or underinsured patients and patient education. (See “What PAs want to learn.”)

For Dr. Torok, the areas of targeted training that PAs identified points to their limited experience with what she calls the “longitudinal problems” that crop up constantly in hospitalized patients.

“These are the issues that come up when you start seeing patients in the hospital longer than expected and you have to start treating them beyond a specific medical condition,” she says. “You have to begin thinking of the goal of care for the patient who may not be going home in three days. That takes special skills.”

The survey revealed another big gap in training around procedures. While the majority of hospitalist PA respondents (67%) reported regularly performing ECGs and X-rays, virtually none performs any invasive procedures.

“It’s not entirely clear whether PAs are not doing procedures because they were never trained to do so or because their job description doesn’t include procedures,” Dr. Torok points out. “If we had PAs who were comfortable doing a lot of different procedures, we would love them.”

Willing to learn
For Dr. Torok, the survey produced this good news: More than 70% of PAs would be willing to take a pay cut to hone their hospital medicine skills. Among respondents, 38% said they’d take a stipend of 50% of a regular hospitalist PA salary to be able to train specifically in hospital medicine, while another 38% said they would need a 75% stipend.

That was all Dr. Torok and her colleagues needed to begin planning an onsite PA post-grad training program. That may begin as early as later this year under the direction of the hospitalist program’s current lead PA.
“We envision it as a 12-month program,” she says. “The main target will be new graduates from PA school. We see it similar to resident training in that we’ll have dedicated physician attendings.” The program will start small and recruit just one PA at first. “We’ll then expand it,” Dr. Torok notes, “if there’s a need and enough resources.”

Phyllis Maguire is Executive Editor of Today’s Hospitalist.