Black and Hispanic Representation Declined After Increased Degree Requirements for Physician Assistants.

PURPOSE: The physician assistant (PA) profession is one of the least racially and ethnically diverse health professions requiring advanced education. New PA graduates are even less diverse than the current PA workforce and less diverse than professions requiring doctoral degrees. Between 1995 and 2020, the percent of all PA graduates that were Black individuals fell from 7% to 3.1%, while Hispanic representation increased from 4.5% to 7.9%. METHODS: Using the federal Integrated Postsecondary Education Data System, we examine the impact of transitions to master's degrees for PAs on Black and Hispanic representation between 1995 and 2020, using individual universities as the unit of analysis. RESULTS: After adjusting for state and year effects, PA programs that transitioned from bachelor's to master's degrees experienced a 5.3% point decline in Black representation and a 3.8% point decline in Hispanic representation. Relative to the already low proportions of Black and Hispanic graduates in PA programs, these declines are significant. CONCLUSION: Steps should be taken to ensure that underrepresented populations have greater access to PA education.

Facilitators to the integration of the first UK-educated physician associates into secondary care services in the NHS.

The physician associate (PA) profession is relatively new to the British NHS. Little research has been conducted on the facilitators to integrating these new health professionals into a secondary care service. Thus, a grounded theory qualitative study was conducted. PAs who were educated in the UK and were the first PA in their secondary care service were interviewed, as well as doctors who were on the team when the PA started. Ten facilitators were identified, comprising three facilitator themes: PA involvement in role and skill development is crucial; having a champion for the PAs promotes integration; and principled behaviour by the PA allows the role to develop safely and effectively. Having a clearly defined role for the PA is the primary facilitating factor. This research identified approaches that both PAs and hospital trusts can implement to facilitate the introduction of PAs to secondary care services in the NHS.

Increasing Knowledge in the Requesting of Clinical Investigations.

PURPOSE: Overtesting, ordering diagnostic investigations that do not help diagnose or manage a patient, is well-recognized as a problem across multiple healthcare settings in developed countries. One of the reasons often cited for overtesting is a lack of confidence or knowledge, so this article addresses our attempt to reduce overtesting through an investigation-specific course for a physician associate (PA) program based in the United Kingdom. We found no evidence of pedagogical literature that focused on clinical diagnostics teaching and assessment for PAs, so we aim to be the first to provide this research. METHODS: To assess student confidence, student feedback was collected through open-ended focus groups and qualitative surveys. The effectiveness of the course was evaluated through students' scores on investigation single best answer assessments. RESULTS: Overall, qualitative feedback from students showed an increase in knowledge in accurate investigation requests and interpretation. Students' assessment scores show a marked improvement after the implementation of the course. CONCLUSION: This approach to an investigation-specific course, with a focus on limiting overinvestigating, demonstrates improved student performance on investigation assessments at the university level.

Validation of a Novel Statistical Method to Identify Aberrant Patient Logging: A Multi-Institutional Study.

INTRODUCTION: Student patient encounter logging informs the quality of supervised clinical practice experiences (SCPEs). Yet, it is unknown whether logs accurately reflect patient encounters, and the faculty resources necessary to review for potential aberrant logging are significant. The purpose of this study was to identify a statistical method to identify aberrant logging. METHODS: A multi-institutional (n = 6) study examined a statistical method for identifying potentially aberrant logging behavior. An automated statistical Mahalanobis Distance (MD) measurement was used to categorize student logs as aberrant if they were identified as probable multivariate outliers. This approach was validated using a gold standard for aberrant logging behavior with manual review by 4 experienced faculty ("faculty consensus") and then comparing interrater agreement between faculty and MD-based categorization. In secondary analyses, we compared the relative accuracy of MD-based categorization to individual faculty categorizing data from their own program ("own program" categorization). RESULTS: 323 student logging records from 6 physician assistant (PA) programs were included. Compared to "faculty consensus" (the gold standard), MD-based categorization was highly sensitive (0.846, 95% CI: 0.650, 1.000) and specific (0.766, 95% CI: 0.645, 0.887). Additionally, there was no significant difference in sensitivity, specificity, positive predictive value, or negative predictive value between MD-based categorization and "own program" categorization. DISCUSSION: The MD-based method of identifying aberrant and nonaberrant student logging compared favorably to the more traditional, faculty-intensive approach of reviewing individual student logging records. This supports MD-based screening as a less labor-intensive alternative to individual faculty review to identify aberrant logging. Identification of aberrant logging may facilitate early intervention with students to improve clinical exposure logging during their SCPEs.

Emergency Physician and Advanced Practice Provider Diagnostic Testing and Admission Decisions in Chest Pain and Abdominal Pain.

OBJECTIVE: We compare utilization of diagnostic resources and admissions in emergency department (ED) patients with chest pain and abdominal pain when managed by advanced practice providers (APPs) and physicians. METHODS: We used 2016 to 2019 data from a national emergency medicine group. We compared visits managed by physicians and APPs based on demographics and observed resource utilization (labs, radiography, computed tomography) use and hospital admission/transfer, stratified by patient age. To reduce selection bias, we created inverse propensity score weights (IPWs). To estimate the average treatment effect for APP visits for each outcome, we included IPWs in a multivariable linear probability model with a dummy variable indicating treatment by an APP and used a facility fixed effect. We then estimated the average treatment effect comparing physician to APP visit for all visits and for discharged visits separately, stratified by the study outcomes. Sensitivity analyses were performed using different cohort definitions and adjusting for past medical history. RESULTS: In chest pain, we included 77,568 visits seen by 1,011 APPs and 586,031 visits seen by 1,588 physicians. In abdominal pain, we included 184,812 ED visits seen by 1,080 APPs and 761,230 visits seen by 1,689 physicians. For both chest pain and abdominal pain visits, physicians saw more older adult patients (55+ years) and admitted a higher percentage of visits than APPs. For chest pain, physicians saw more circulatory system diseases (70.7% vs. 58.6%); APPs saw more respiratory system diseases (17.1% vs. 9.8%). In abdominal pain, emergency physicians saw more digestive system diseases (28.5% vs. 23.3%); APPs saw more genitourinary system diseases. After matching with IPW, predicted probabilities of laboratory, radiology, and admissions either did not vary or were slightly lower for APPs compared to physicians for all outcomes. Sensitivity analyses showed similar results, including controlling for past medical history. CONCLUSION: Diagnostic testing and hospitalization rates for chest pain and abdominal pain between APPs and physicians is largely similar after matching for severity and complexity. This suggests that APPs do not have observably higher use of ED and hospital resources in these conditions in this national group.

The Impact of Advanced Practice Provider Staffing on Emergency Department Care: Productivity, Flow, Safety, and Experience.

OBJECTIVES: We examined emergency department (ED) advanced practice provider (APP) productivity and how APP staffing impacted ED productivity, safety, flow, and experience. METHODS: We used 2014 to 2018 data from a national emergency medicine group. The exposure was APP coverage: APP hours as a percentage of total clinician hours at the ED-day level. Multivariable regression was used to assess the relationship between APP coverage and productivity outcomes (patients/clinician hour, relative value units [RVUs]/clinician hour, RVUs/visit, and RVUs/salary-adjusted hour), flow outcomes (length of stay and left without treatment), safety (72-hour returns, incident reports), and experience (Press-Ganey scores), adjusting for patient and facility characteristics. RESULTS: In 13.02 million patient visits in 105,863 ED-days across 94 EDs from 2014 to 2018, nurse practitioners and physician assistants managed 5.4 and 18.6% of visits independently, 74.6% by emergency physicians alone, and 1.4% jointly. APP visits had lower RVUs/visit (2.8 vs. 3.7) and lower patients/hour (1.1 vs. 2.2) compared to physician visits. Higher APP coverage (by 10%) at the ED-day level was associated with lower patients/clinician hour by 0.12 (95% confidence interval [CI] = -0.15 to -0.10) and lower RVUs/clinician hour by 0.4 (95% CI = -0.5 to -0.3). There was no impact of increasing APP coverage on RVUs/salary-adjusted hour or RVUs/visit. There was also no effect of increasing APP coverage on flow, safety, or patient experience. CONCLUSION: In this group, APPs treated less complex visits and half as many patients/hour compared to physicians. Higher APP coverage allowed physicians to treat higher-acuity cases. We found no economies of scale for APP coverage, suggesting that increasing APP staffing may not lower staffing costs. However, there were also no adverse observed effects of APP coverage on ED flow, clinical safety, or patient experience, suggesting little risk of increased APP coverage on clinical care delivery.

Explosive Growth in British Physician Associate Education Since 2008.

Physician associate (PA) education in the United Kingdom has grown substantially since the establishment of 4 PA education programs in the late 2000s. From those 4 programs in 2008, the number of universities educating PAs fell to a nadir of 2 programs in 2012 and then rose to 29 by the end of 2017. Due to program closures, the number of students enrolled in the early years fluctuated substantially. In 2008, 43 students entered PA education; in 2010, only 17 students started PA training, but in 2017, the number of students enrolled in PA programs soared to 853. Early in the course of PA education, programs were only offered in the greater London and West Midlands areas of England. As of 2017, PAs were being educated in all 4 countries of the United Kingdom, although the explosive growth in the number of programs is expected to slow as 2020 nears.

Diverting dementia: Reducing the risk of cognitive loss.

As the population ages, more adults in the United States are living with dementia. Younger family members often are concerned that they too may develop dementia, but the general public is largely unaware that strategies exist to slow or delay onset of dementia. In fact, by implementing a number of healthful strategies throughout their lifespans, patients may be able to reduce the likelihood of developing dementia or at least delay its onset. These strategies include eating a high-quality diet; keeping physically, socially, and intellectually active; preventing or treating hearing loss; avoiding obesity, hypertension, and diabetes; and avoiding or stopping tobacco smoking. This article reviews the recent scientific literature for dementia risk-reduction strategies and offers suggestions to healthcare professionals who wish to help their patients stave off cognitive loss.

Physician assistants in urgent care.

OBJECTIVE: To describe the characteristics of physician assistants (PAs) who practice urgent care. METHODS: Data from national surveys conducted by the American Academy of PAs (AAPA) between 1998 and 2016 were analyzed, comparing PAs who practice in urgent care, emergency medicine, and all other specialties. RESULTS: The percentage of PAs who work in an urgent care setting has nearly doubled in the last 10 years. PAs who work in urgent care see more patients and perform more minor surgical procedures than those in emergency medicine. They are less likely to be newly graduated PAs than those in emergency medicine. PAs in urgent care are less likely than other PAs to consult a physician about their patients in real time. CONCLUSION: The number of PAs practicing urgent care is increasing. More research is needed to further characterize PA practice in this specialty.

Job satisfaction among British physician associates.

All British physician associates (PAs) were invited to participate in the annual census of the UK Association of Physician Associates (UKAPA) in May 2014. Each participant completed the Cooper 10-item Job Satisfaction Scale and a PA-specific job satisfaction survey. In general, PAs were found to be satisfied with their work. No factor assessed by the survey had lower than a 66.6% satisfaction rate. Of the factors assessed, PAs were most satisfied with their relationships with the doctors on their teams. They were least satisfied with their ability to use their training and abilities, with only 66.6% of participants reporting satisfaction with this aspect of their work. Like their American colleagues, British PAs are generally satisfied with their work. They are least satisfied with their ability to fully use their training, which is likely due to the youth of the profession, lack of prescriptive rights and lack of understanding of the PA role.

Frequency and Confidence of Healthcare Practitioners in Encountering and Addressing Nutrition-Related Issues.

OBJECTIVE: Identify the frequency of nutrition issues encountered by healthcare professionals and their confidence in addressing these issues. METHODS: A survey designed to assess the frequency and type of nutrition issues most often encountered in practice of a variety of healthcare professionals and the practitioners' confidence in addressing nutrition issues was developed and distributed to 5,729 graduates from an academic medical center. Descriptive statistics were calculated for all variables. Logistic regression models were used to find predictors of confidence. RESULTS: The final response rate was 17.2% (n=987). The most common nutrition-related problems encountered included obesity (43.8%), diabetes mellitus (43%), and cardiovascular disease (37.1%). Nutrition issues were encountered daily or weekly by 70.5% of healthcare providers, but only 24.8% felt "very confident" in addressing nutrition issues. Significant predictors of confidence included number of years working, more frequent nutrition-related encounters, and nutrition education in professional programs. CONCLUSION: Healthcare practitioners encounter nutrition issues frequently in practice and often do not have a high level of confidence in addressing these issues.

Managing nonteratogenic adverse reactions to isotretinoin treatment for acne vulgaris.

Isotretinoin is the strongest, most effective oral treatment for patients with severe acne vulgaris, with remission rates of 89% and higher. Because of its potency, isotretinoin causes many adverse reactions. This article reviews common and severe adverse reactions to isotretinoin and how providers can best manage these reactions. Because of inconclusive research on the correlation between isotretinoin and depression and irritable bowel syndrome, providers should ask patients about symptoms monthly. Prescribing micronized isotretinoin and starting at the lowest dose with gradual upward titration also can help reduce the incidence of adverse reactions.

Building a research culture in physician assistant education.

The mission of most physician assistant (PA) programs is to train clinically competent health care providers. While essential and compelling, we believe this mission is insufficient for modern PA programs and advocate that programs take steps to institute and expand their research capabilities and activities. This will represent a culture shift for many institutions but is necessary for the long-term growth and survival of PA educational programs within US higher education. We discuss the obstacles that exist to create a flourishing research culture in PA programs and offer concrete recommendations for programs to attain such an environment.

Satisfaction of doctors with the role of physician associates.

Physician associates (PAs) are a new profession to the UK. There has been no prior national assessment of the perspectives of doctors who work with PAs with regard to their role. Doctors who supervise PAs were surveyed in late 2012; respondents were found generally to be satisfied with the role of PAs and believed that the addition of the PA to the team benefited doctors and patients. Doctors reported that they have received positive feedback from patients about the role of PAs as well. Respondents believe that the current unregulated status of the profession impairs their ability to use their PA staff to their fullest potential.

Differences in the delivery of health education to patients with chronic disease by provider type, 2005-2009.

INTRODUCTION: Health education provided to patients can reduce mortality and morbidity of chronic disease. Although some studies describe the provision of health education by physicians, few studies have examined how physicians, physician assistants, and nurse practitioners differ in the provision of health education. The objective of our study was to evaluate the rate of health education provision by physicians, physician assistants, and nurse practitioners/certified midwives. METHODS: We analyzed 5 years of data (2005-2009) from the outpatient department subset of the National Hospital Ambulatory Medical Care Survey. We abstracted data on 136,432 adult patient visits for the following chronic conditions: asthma, chronic obstructive pulmonary disease (COPD), depression, diabetes, hyperlipidemia, hypertension, ischemic heart disease, and obesity. RESULTS: Health education was not routinely provided to patients who had a chronic condition. The percentage of patients who received education on their chronic condition ranged from 13.0% (patients with COPD or asthma who were provided education on smoking cessation by nurse practitioners) to 42.2% (patients with diabetes or obesity who were provided education on exercise by physician assistants). For all conditions assessed, rates of health education were higher among physician assistants and nurse practitioners than among physicians. CONCLUSION: Physician assistants and nurse practitioners provided health education to patients with chronic illness more regularly than did physicians, although none of the 3 types of clinicians routinely provided health education. Possible explanations include training differences, differing roles within a clinic by provider type, or increased clinical demands on physicians. More research is needed to understand the causes of these differences and potential opportunities to increase the delivery of condition-specific education to patients.