Nurse practitioners, physician assistants, and trust: A systematic review.

BACKGROUND: The use of physician extenders (e.g., nurse practitioners [NPs] and physician assistants [PAs]) has risen in recent years in the U.S. health care domain, yet some scholars have questioned if physician extenders are being fully utilized in the health care field. PURPOSES: The purpose of this research was to conduct a systematic review to determine if trust in the NP/PA might be influential in the ways these professionals are utilized. We view trust through the lens of Mayer et al. and their model of organizational trust, and we seek to examine how patients, physicians, and NPs/PAs themselves view one another. METHODS: This systematic review spanned from 1996 to 2022 and applied the Preferred Reporting Items for Systematic Reviews and Meta-Analyses strategy. The final sample consisted of 29 articles. RESULTS: The findings point to how the antecedents of trust according to Mayer et al.; i.e., trustee's ability, benevolence, and integrity) influence the trusting relationships between patients and NPs/PAs and between physicians and NPs/PAs. Consequences and outcomes of trust are also discussed. Importantly, a trustor's propensity to trust and repeat interactions over time (e.g., feedback loop) is influential to trusting relationships. PRACTICE IMPLICATIONS: These findings offer health care organizations insight into the mechanisms for building trust as physician extenders become more prominent in the health care field.

Gendered racial microaggressions and stress in PAs who are Black women.

OBJECTIVE: This mixed-methods study explored whether physician associates/assistants (PAs) who are Black women (for brevity, called Black women PAs throughout this article) experience gendered racial microaggressions and whether these experiences correlated with psychologic distress. The phrase Black women encompasses those who identify with the sociocultural roles, behaviors, and expressions of being a Black woman. METHODS: We conducted an online survey of Black women PAs using the Gendered Racial Microaggressions Scale during a 2-month period in 2019. RESULTS: Black women PAs experienced gendered racial microaggressions in clinical settings. Gendered racial microaggressions were correlated with stress, being silenced and marginalized, and assumptions of beauty and sexual objectification. No correlations were found between stress and the angry Black woman and strong Black woman variables. CONCLUSIONS: This study revealed that Black women have interlocking forms of oppression related to their race and gender, which are associated with psychologic distress. Awareness of these occurrences can reduce the unknowing perpetuation of gendered racial microaggressions and create cultural awareness practices.

Career flexibility for PAs: What makes switching specialties successful?

ABSTRACT: Switching specialties is common among physician associates/assistants (PAs) and important in combating burnout. Despite this, little is known about the PA experience with switching specialties. This study sought to identify factors associated with successfully switching specialties using semistructured interviews with PAs and hiring managers. Participants reported that switching specialties was initially challenging for managers and PAs because of insufficient onboarding and unrealistic expectations, but they also reported that they were generally satisfied with long-term outcomes. Our findings suggest that PAs hoping to switch specialties may want to focus on building a professional network, identifying areas where they can highlight relevant experience, and demonstrating their intent to remain in that role. Hiring managers could benefit from considering their hiring practices and tailoring onboarding expectations for new hires.

Burnout among palliative care providers.

BACKGROUND: Burnout among health care professionals contributes to high job turnover. Within the United States, burnout among specialty palliative care (PC) providers will accentuate provider shortage problems. OBJECTIVES: This systematic review was conducted to answer the question "what is known about burnout among specialty PC providers practicing in the United States?" More specifically, it was designed to identify the rate of burnout and factors that influence or mitigate it among PC nurse practitioners (NPs), physician assistants (PA), and physicians and to inform future research. DATA SOURCES: An electronic literature search of studies conducted in the United States between 2012 and September 2022 was completed in Embase, PubMed, CINAHL, and PsycINFO. CONCLUSIONS: Analysis of 14 studies showed that there are five primary themes related to burnout among PC providers: (1) the rate of burnout, (2) the physical, psychological, and clinical manifestations of burnout, (3) predictors of burnout, (4) factors of resiliency, and (5) interventions piloted to decrease burnout. The majority of studies have delineated the physician role but have failed to determine the rate and factors of burnout among PC NPs and PAs. IMPLICATIONS FOR PRACTICE: As NPs and PAs are integral to the PC provider workforce, future research should be designed to understand more clearly how burnout affects these two PC roles to inform efforts to sustain the PC workforce.

Working conditions, authorizations, mental health, and job satisfaction of physician assistants in Germany.

Objective: This study explores associations among the overall and facet-specific job satisfaction, work-related factors, responsibilities, and mental health of physician assistants (PAs) in Germany to identify factors that prolong the lifetime and wellbeing of PAs in practice and to counteract the shortage of healthcare staff. Methods: An online survey comprising sociodemographic and work-related items, items from the short questionnaire of general and facet-specific job satisfaction (KAFA), and the Depression, Anxiety, and Stress Scale (DASS-21) were distributed to PAs working in Germany in 2021 (cross-sectional survey design). Descriptive statistics, DASS-21 subscale score analysis, t-test, ANOVA, or Kruskal-Wallis test was used. Results: PAs (n = 169) were working mainly in surgery (23.2%), internal medicine (20.3%), or orthopedics and trauma surgery (17.5%), whereas only a few PAs were working in emergency care, geriatrics, neurology, or oncology. They were responsible for a broad spectrum of medical activities depending on the practice setting. PAs working in emergency care claimed to be the most empowered, followed by PAs in orthopedics and surgery. Almost all PAs carried out documentation, anamnesis, and diagnostic services. Although almost all PAs rated their overall job satisfaction as good, satisfactory, or pleasant (91.6%), single facets of job satisfaction were rated differently. Colleagues and supervisors were assessed very positively, whereas payment and professional activities were rated rather average and development opportunities even worse. PAs working in oncology demonstrated the highest overall job satisfaction, followed by PAs working in geriatrics and emergency care. Overall job satisfaction was significantly negatively associated with depression, anxiety, and stress scores (p ≤ 0.001, p ≤ 0.05, and p ≤ 0.05, respectively). Particularly, female gender, having an urban residence, and PAs working in oncology demonstrated significantly increased anxiety scores. Moreover, depression scores of PAs working in oncology or neurology or with a low net income exceeded critical cutoff values. Conclusion: Interventions aimed at removing the significant negative correlation among job satisfaction, depression, anxiety, and stress scores are needed. To retain PAs in their jobs, salary, autonomy, and development opportunities should be improved and prevention programs for anxiety and depression should be offered. Remarkably, PAs' overall good job satisfaction was mainly determined by good evaluations of supervisors and colleagues.

Assessing the Effect of the COVID-19 Outbreak on Didactic Education and Mental Health of Physician Assistant Students in the New York City Region.

INTRODUCTION: COVID-19 has profoundly affected life throughout the world, and it greatly impacted physician assistant (PA) education programs when the virus spread across the New York region 2 years ago. PA programs at Stony Brook University, Hofstra University, and the New York Institute of Technology were located in the epicenter of the pandemic and were forced to transition to online learning during the spring of 2020. The purpose of this study was to explore didactic PA students' perceptions of virtual learning, their mental health status, and the challenges and unexpected benefits they have faced during this historic time. METHODS: A consent form that linked to an 11-question electronic Qualtrics survey was emailed to all didactic students enrolled in the 3 participating PA programs. The survey data were used to conduct a descriptive analysis and a Spearman's ρ correlation analysis using SPSS 24 software. RESULTS: The survey response rate was 39% (89/229). The students perceived it to be more challenging to maintain the same level of academic achievement with virtual learning, although they felt they were able to meet learning objectives and be prepared for clinical clerkships. They reported experiencing greater stress, anxiety, and depression related to decreased socialization and isolation. However, the students said that their PA program provided enough support to assist with student needs, and they noted unexpected benefits of remote learning, including more time to spend with family members, increased schedule flexibility, and lower commuting costs. DISCUSSION: The PA students' education and mental health were negatively affected because of the abrupt transition from in-person to virtual learning. At the height of the COVID-19 pandemic, most of the students in the 3 participating PA programs in New York were affected by the change to remote learning and the subsequent lack of socialization. PA students experienced both challenges and benefits during this unscheduled virtual learning period. While students noted increases in mental health issues, they felt supported by faculty members and prepared to start clinical rotations.

Medicosocial Conflict and Crisis due to Illegal Physician Assistant System in Korea.

The Korean Medical Association opposes the illegal attempt to implement the physician assistant (PA) system in Korea. The exact meaning of 'PA' in Korea at present time is 'Unlicensed Assistant (UA)' since it is not legally established in our healthcare system. Thus, PA in Korea refers to unlawful, unqualified, auxiliary personnel for medical practitioners. There have been several issues with the illegal PA system in Korea facing medicosocial conflicts and crisis. Patients want to be diagnosed and treated by medically-educated, licensed and professionally trained physicians not PAs. In clinical settings, PAs deprive the training and educational opportunities of trainees such as interns and residents. Recently, there have been several attempts, by CEO or directors of major hospitals in Korea, to adopt and legalize this system without general consensus from medical professional associations and societies. Without such consensus, this illegal implementation of PA system will create new and additional very serious medical crises due to unlawful medical, educational, professional conflicts and safety issues in medical practice. Before considering the implementation of the PA system, there needs to be a convincing justification by solving the fundamental problems beforehand, such as the collapsed medical delivery system, protection and provision of optimal education program and training environment of trainees, burnout from excessive workloads of physicians with very low compensational system and poor conditions for working and education, etc.

Clinician Conceptualization of the Benefits of Treatments for Individual Patients.

Importance: Knowing the expected effect of treatment on an individual patient is essential for patient care. Objective: To explore clinicians' conceptualizations of the chance that treatments will decrease the risk of disease outcomes. Design, Setting, and Participants: This survey study of attending and resident physicians, nurse practitioners, and physician assistants was conducted in outpatient clinical settings in 8 US states from June 2018 to November 2019. The survey was an in-person, paper, 26-item survey in which clinicians were asked to estimate the probability of adverse disease outcomes and expected effects of therapies for diseases common in primary care. Main Outcomes and Measures: Estimated chance that treatments would benefit an individual patient. Results: Of 723 clinicians, 585 (81%) responded, and 542 completed all the questions necessary for analysis, with a median (interquartile range [IQR]) age of 32 (29-44) years, 287 (53%) women, and 294 (54%) White participants. Clinicians consistently overestimated the chance that treatments would benefit an individual patient. The median (IQR) estimated chance that warfarin would prevent a stroke in the next year was 50% (5%-80%) compared with scientific evidence, which indicates an absolute risk reduction (ARR) of 0.2% to 1.0% based on a relative risk reduction (RRR) of 39% to 50%. The median (IQR) estimated chance that antihypertensive therapy would prevent a cardiovascular event within 5 years was 30% (10%-70%) vs evidence of an ARR of 0% to 3% based on an RRR of 0% to 28%. The median (IQR) estimated chance that bisphosphonate therapy would prevent a hip fracture in the next 5 years was 40% (10%-60%) vs evidence of ARR of 0.1% to 0.4% based on an RRR of 20% to 40%. The median (IQR) estimated chance that moderate-intensity statin therapy would prevent a cardiovascular event in the next 5 years was 20% (IQR 5%-50%) vs evidence of an ARR of 0.3% to 2% based on an RRR of 19% to 33%. Estimates of the chance that a treatment would prevent an adverse outcome exceeded estimates of the absolute chance of that outcome for 60% to 70% of clinicians. Clinicians whose overestimations were greater were more likely to report using that treatment for patients in their practice (eg, use of warfarin: correlation coefficient, 0.46; 95% CI, 0.40-0.53; P < .001). Conclusions and Relevance: In this survey study, clinicians significantly overestimated the benefits of treatment to individual patients. Clinicians with greater overestimates were more likely to report using treatments in actual patients.

Arthroplasty implants and materials: Cost awareness and value perception.

Arthroplasty procedures are commonly performed and contribute to healthcare expenditures seen in the United States. Surgical team members may make selections among implants and materials without always knowing their relative cost. The current study reports on a survey aimed to investigate the perceptions of an academic group about the relative cost and value of commonly used operating room implants and materials related to joint arthroplasty cases using 10 matched pairs of items. Of the 124 persons eligible to take the survey, 102 responded (response rate of 82.3%) including attendings, fellows, residents, physician assistants (PAs), advanced practice registered nurses (APRNs) and registered nurses (RNs). On average for the ten pairs of items, the more expensive items were correctly selected by 90.2+/-13.9% (mean+/- standard deviation) of respondents with a range from 54.9% to 100%. Of note, the cost differences were significantly overestimated for 8/10 item pairs. The majority of respondents perceived the more expensive item as the item with the higher clinical value for 9/10 item pairs. Most arthroplasty attendings (91.3%) indicated willingness to use the less expensive item of two similar items. Nonetheless, 17.9% of fellows, residents, PAs, APRNs and RNs indicated that they would not feel comfortable suggesting using the less expensive item. Although attending arthroplasty surgeons stated a desire to consider costs, a knowledge deficit with regards to identifying the extent of cost differences was identified, and a significant portion of the surgical support team reported being hesitant to suggest less expensive options.

Hospitalist perspectives on barriers to recommend and potential benefit of the COVID-19 vaccine.

Background: Hospitalists, comprised of nurse practitioners and physician assistants (collectively, advanced practice providers [APPs]) and physicians, have opportunities to counsel patients and reduce SARS-CoV-2 related coronavirus disease 2019 (COVID-19) vaccine hesitancy. However, hospitalist perspectives on the COVID-19 vaccine and potential differences between APPs and physicians are unknown. Understanding hospitalist perspectives could help to address vaccine hesitancy among patients.Methods: We conducted an online survey of hospitalists at Mayo Clinic sites in Arizona, Florida, Minnesota, and Wisconsin from 14 December 2020 through 4 January 2021. We collected demographic information and assessed perspectives on the COVID-19 vaccine and, for comparison, on the influenza vaccine. Descriptive statistics were used to compare responses between APPs and physicians.Results: The overall response rate was 42.7% (n = 128/300) and comprised of 53.9% women (n = 69/128) and 41.4% APPs (n = 53/128). Most hospitalists reported receiving or planning to receive vaccination against COVID-19 (93.7%; n = 119/128) and influenza (97.7%; n = 125/128). Most hospitalists reported they would advise 100% of patients to receive the COVID-19 vaccine (66% for APPs; 74.7% for physicians) and influenza vaccine (83% for APPs; 80% for physicians). Barriers to recommending the COVID-19 vaccine included patient health status and vaccine safety profile. Hospitalists reported that patients and coworkers receiving the COVID-19 vaccine would reduce their anxiety (~80% of hospitalists), social isolation (~64% of hospitalists), and improve their emotional support (~40% of hospitalists). APP and physician responses were similar. The possible reduction in social isolation was associated with higher odds of hospitalists advising all patients to receive the COVID-19 vaccine (adjusted odds ratio 2.95 [95% confidence interval, 1.32-6.59]; P< .008), whereas hospitalist age, gender, and profession showed no association.Conclusion: Most hospitalists would reportedly advise patients to receive the COVID-19 vaccine. Barriers to this recommendation included patient health status and vaccine safety. Hospitalists are an important resource to provide patient education and reduce COVID-19 vaccine hesitancy.

What Influences Choice of Continuing Medical Education Modalities and Providers? A National Survey of U.S. Physicians, Nurse Practitioners, and Physician Assistants.

PURPOSE: To explore what influences clinicians in selecting continuing medical education (CME) activities in the United States. METHOD: In August 2018, the authors conducted an Internet-based national survey, sampling 100 respondents from each of 5 groups: family medicine physicians, internal medicine and hospitalist physicians, medicine specialist physicians, nurse practitioners, and physician assistants. In total, 1,895 clinicians were invited and 500 (26%) responded. Questions addressed the selection and anticipated use of CME delivery modalities and perceived characteristics of specific CME providers. Response formats used best-worst scaling or 5-point ordinal response options. RESULTS: The factors identified as most important in selecting CME activities were topic (best-worst scaling net positivity 0.54), quality of content (0.51), availability of CME credit (0.43), and clinical practice focus (0.41), while referral frequency (-0.57) ranked lowest. The activities that the respondents anticipated using most in the future were live (mean 3.8 [1 = not likely, 5 = very likely]), online (mean 3.5), point-of-care (mean 3.5), and print-based (mean 3.5) activities. For online CME, the features of greatest appeal were that learning could be done when clinicians had time (mean 4.4), at their own pace (mean 4.2), and at lower cost (mean 4.2). For live CME, the features of greatest appeal were that the subject was best taught using this modality (mean 4.0), or the activity was located in a destination spot (mean 4.0) or a regional location (mean 3.9). When rating specific CME providers, most academic institutions received relatively high ratings for research focus and clinical practice focus, whereas commercial providers had slightly higher ratings for ease of access. Responses were generally similar across clinician types and age groups. CONCLUSIONS: Physicians, nurse practitioners, and physician assistants are interested in using a variety of CME delivery modalities. Appealing features of online and live CME were different.

Perceptions of Role Transition into Practice among Advanced Practice Providers and Physicians.

This study sought to examine the experiences of advanced practice providers (APPs) as an approach to inform the development of formalized programs for transition into practice and to compare APP (N = 122) and physician (N = 84) perceptions of the novice practitioners' acclimation into a provider role within the first year of practice. Using a cross-sectional survey design, two separate web-based questionnaires were distributed to APPs and physicians. The APPs' perspectives echoed findings of earlier studies with regard to perceived confidence, feelings of anxiety/fear, and inadequacy. In 16 of 23 paired items, physicians and APPs had similar perspectives about confidence/competence after orientation. Significant differences in their perceptions included amount of physician support, time management, length of time to become a fully functional APP, and independence. Better understanding of the perceptions of APPs and physicians can augment APP preparation for a shifting workforce composition and team-based, interprofessional practice designed to meet the population's health care needs.

Are Health Care Professionals' Implicit and Explicit Attitudes Toward Conventional Disease-Modifying Antirheumatic Drugs Associated With Those of Their Patients?

OBJECTIVE: It is generally unknown how the attitudes and beliefs of health care professionals (HCPs) might affect the attitudes, beliefs, and medication-taking behavior of patients with rheumatoid arthritis (RA). This study aims 1) to examine the attitudes, health-related associations (both implicit and explicit), and beliefs of HCPs about conventional disease-modifying antirheumatic drugs, and 2) to assess whether these attitudes, health-related associations, and beliefs of HCPs are associated with those of their patients, with their patients' medication-taking behavior, and disease activity. METHODS: HCPs were recruited from 2 centers that specialized in rheumatology across The Netherlands, and patient recruitment followed. In this observational study, implicit outcomes were measured with single-category implicit association tests, whereas explicit outcomes were measured with a bipolar evaluative adjective scale and the Beliefs About Medicines Questionnaire-Specific. Spearman's rank correlations were used to describe correlations between implicit and explicit measures of the attitudes of HCPs. Multilevel, mixed-effects linear models were used to examine the association of HCP-related characteristics, including the implicit and explicit outcomes of HCPs, with those of their patients, their medication-taking behaviors, and disease activity. RESULTS: Of the 1,659 initially invited patients, 254 patients with RA (mean age 62.8 years, mean disease duration 11.8 years, and 68.1% of the patients were female) who were treated by 26 different HCPs agreed to participate in this study. The characteristics, attitudes, health-related associations, and beliefs about medicines of HCPs were not significantly associated with those of their patients, nor with their medication-taking behaviors or disease activity scores. CONCLUSION: This study demonstrated that the attitudes, health-related associations (as measured both implicitly and explicitly), and beliefs of HCPs were not significantly associated with the attitudes, beliefs, medication-taking behavior, and disease activity of patients with RA.

Emerging practices in onboarding programs for PAs: Strategies for onboarding.

OBJECTIVE: This is the final article in a series that examines the role of onboarding programs for new physician assistants (PAs) and NPs. On-the-job learning is highly relevant for this workforce. Here we examine the strategies organizations use to impart information and skills in onboarding programs. METHODS: In 2018, we interviewed 13 administrators of onboarding programs. Interviews were transcribed and analyzed for themes by a team of researchers, with feedback from interviewees. RESULTS: Seven strategies were identified and are described in this article: Clinical mentoring, personal and professional mentoring, meeting with/shadowing other professionals, checking in by administrators, delivering didactic content, tailoring content or ramp-up, and assessing/ensuring competency. CONCLUSIONS: This article describes commonly used strategies in onboarding programs for PAs and NPs and can provide guidance to those designing their own onboarding programs. The programs we examined relied heavily on mentoring and other strategies appropriate for adult learners. Future work should evaluate the effectiveness of onboarding programs.

Practice assistants´ perceived mental workload: A cross-sectional study with 550 German participants addressing work content, stressors, resources, and organizational structure.

INTRODUCTION: Practice assistants represent a highly relevant occupational group in Germany and one of the most popular training professions in Germany. Despite this, most research in the health care sector has focused on secondary care settings, but has not addressed practice assistants in primary care. Knowledge about practice assistants' workplace-related stressors and resources is particularly scarce. This cross-sectional study addresses the mental workload of practice assistants working in primary care practices. METHODS: Practice assistants from a network of 185 German primary care practices were invited to participate in this cross-sectional study. The standardized `Short Questionnaire for Workplace Analysis' (German: Kurzfragebogen zur Arbeitsanalyse) was used to assess practice assistants´ mental workload. It addresses eleven workplace factors in 26 items: versatility, completeness of task, scope of action, social support, cooperation, qualitative work demands, quantitative work demands, work disruptions, workplace environment, information and participation, and benefits. Sociodemographic and work characteristics were also obtained. A descriptive analysis was performed for sociodemographic data and "Short Questionnaire for Workplace Analysis" factors. The one-sided t-test and Cohen´s d were calculated for a comparison with data from 23 professional groups (n = 8,121). RESULTS: A total of 550 practice assistants from 130 practices participated. The majority of practice assistants was female (99.3%) and worked full-time (66.5%) in group practices (50.6%). Compared to the other professional groups, practice assistants reported higher values for the factor social support (4.0 versus 3.7 [d 0.44; p<0.001]), information and participation (3.6 versus 3.3 [d 0.38; p<0.001] as well as work disruptions (2.7 vs. 2.4 [d 0.42; p<0.001]), while practice assistants showed lower values regarding scope of action (3.4 versus 3.8 [d 0.43; p<0.001]). CONCLUSIONS: Our study identified social support and participation within primary care practices as protective factors for mental workload, while work disruptions and scope of action were perceived as stressors.

Assessment of primary care practitioners' attitudes and interest in pharmacogenomic testing.

Aims: Identify the attitudes and interests of primary care providers (PCPs) in applying clinical pharmacogenomics (PGx) test results. Materials & methods: A questionnaire was designed and then disseminated to PCPs across the MedStar Health System. Results: Ninety of 312 (29%) PCPs responded and were included in analyses. Seventy-six (84%) had heard of PGx and 12 (13%) previously ordered PGx testing. Most, 68 (76%), believed PGx can improve care; however, a minority, 23 (26%), reported confidence in using PGx in prescribing decisions. Sixty-four (70%) wanted a pharmacist consultation. PCPs desired PGx for antidepressants (75%), proton pump inhibitors (72%) and other medications. Conclusion: Most PCPs felt unprepared to interpret PGx results and desired pharmacist consultations. These data can inform future PGx implementations with PCPs.