The Essential Role of Physician Assistants in Rheumatology Save

Physician assistants (PAs) have been integral to the delivery of healthcare since the inception of the profession in the late 1960s. The concept of the PA role evolved in an effort to solve the shortage of primary care providers in the USA. We continue to face dizzying shortages of clinicians not only in primary care, but also in specialties due to the growing demands of our aging population and the need to optimize delivery of care to those in rural or urban areas. This supply and demand issue is undoubtedly felt strongly in rheumatology. 

Advanced practice providers such as PAs are well-equipped to improve the delivery and quality of health care to patients with rheumatic diseases. 

Ready to bring a PA into your rheumatology practice? This blog post breaks down the key facts you need to know about PA training, scope of practice, and the recent changes to the profession's title.

PA Training

PAs complete a 2-year master’s program which is split into a didactic and clinical year of training. The didactic year consists of lectures and labs akin to a condensed version of the initial phases of medical school. The clinical year of PA training involves a standardized set of core rotations similar to medical school clerkships. These rotations include: psychiatry, emergency medicine, family medicine, internal medicine, pediatrics, surgery, and women's health. Each rotation is followed by a standardized examination. Additionally, PA programs offer elective rotations. Selection of specialties such as rheumatology may be limited by availability. At the end of the training program, PAs sit for the Physician Assistant National Certifying Examination (PANCE), a formal 6 hour board examination after which the formal title of PA-Certified (PA-C) is granted upon receipt of a passing score. The PA-C will then go on to apply for licensure within his or her respective state of practice. In order to maintain certification, PAs must complete 100 hours of CME every 2 years and re-certify every 10 years by formal examination.

Laws and Scope of Practice

PAs practice in a variety of outpatient and inpatient settings in all US states and Washington, D.C. In the majority of states, it is requisite for a PA to have an established collaborative agreement with an individual physician or physician group if employed in a larger organization such as a hospital. This agreement is a formal document that outlines the scope within which the PA will practice and the extent to which the PA will be supervised by the physician or physician group. The concept of “supervision” can be very confusing, particularly for office managers or physicians who do not have experience in hiring a PA. Supervision for a newly graduated PA will look quite different than that of a PA with years of experience. The most important takeaway regarding the collaborative agreement is the ability for it to be modified over time as the PA becomes seasoned and takes on more responsibilities of patient care. Another note on “supervision”: in most states, the term supervision need not be taken literally. In other words, a PA may practice at an office location without the physical presence of a physician so long as the collaborative agreement has put into place a method of communication between the PA and physician should the need for consultation arise.

PAs have prescriptive ability to write for medications including schedule II-IV drugs without legal requirement for co-signature in most states. The guidelines for prescribing certain medications, including controlled substances, should be addressed in the collaborative agreement. It may be relevant to include detailed procedures for prescribing certain therapeutics such as intravenous biologics or highly toxic drugs such as cyclophosphamide in this agreement.

There may be caveats in individual states restricting PA practice for specific procedures or tasks. For example, in my state of Michigan, our health code restricts PAs from determining the refractive state of the eye i.e. “better one or better two”? These details can be found in your state’s health code.

Professional Title Change

The title of “physician assistant” has been utilized since the creation of the profession; however, our name has recently undergone some changes in the last few years. To preface, there has been debate within our professional society for decades, calling for a reappraisal of the “assistant” portion of the PA title. The aim has been to better articulate the scope of PAs given that our practice involves making diagnoses, writing prescriptions, interpreting diagnostic studies, performing medical procedures, and serving as advisors to industry and government-based organizations. 

The title of “physician associate” (still PA!) was officially coined in 2021 and is included in the current title of our professional society The American Academy of Physician Associates. Various state level professional societies have adopted the name change as well. The adoption of the title into state health codes has been slow as this requires passing a bill through the state legislature. Oregon, Maine and New Hampshire have thus far made changes into their health code officially changing the title. In all other states, the age-old title will continue to be utilized until nomenclature changes are introduced as sponsored bills.