Physician assistant

Overview
In the United States, a physician assistant (PA) is an advanced practice clinician licensed to practice medicine with the supervision of a licensed physician. PAs are not to be confused with medical assistants, who perform administrative and clinical tasks in hospitals and clinics under the direct supervision of physicians, registered nurses, nurse practitioners, or PAs.

History of the profession
The PA profession came into existence in the mid-1960s due to the shortage and uneven geographic distribution of primary care physicians in the United States. Dr. Eugene Stead of the Duke University Medical Center in North Carolina assembled the first class of PAs in 1965, composed of former U.S. Navy hospital corpsmen and U.S. Army combat medics, who had received considerable medical training during their military service and gained valuable experience during the Vietnam War. He based the curriculum of the PA program in part on his first-hand knowledge of the fast-track training of medical doctors during World War II.

The Duke University Medical Center Archives has established the Physician Assistant History Center, dedicated to the study, preservation, and presentation of the history of the PA profession.

Education and certification
As of May 2008, there were 141 PA programs in the United States accredited by the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA). The majority are graduate programs leading to the award of master's degrees in either Physician Assistant Studies (MPAS), Health Science (MHS), or Medical Science (MMS), and require a bachelor's degree and GRE or MCAT scores for entry. Some PA programs are starting to offer a clinical doctorate degree; Doctor of Science Physician Assistant (DScPA), while a remaining few still lead to the award of an undergraduate bachelor's or associate's degree, but many of these are transitioning to graduate-level training.

PA education is based on the medical school model, although unlike medical school which lasts four years, PA training is usually 2 to 3 years in duration. It is generalist in approach, consisting of classroom and laboratory instruction in medical and behavioral sciences, such as anatomy, microbiology, pharmacology, pathophysiology, hematology, pathology, clinical medicine, and physical diagnosis, followed by clinical rotations in internal medicine, family medicine, surgery, pediatrics, obstetrics and gynecology, oncology, emergency medicine, and geriatric medicine, as well as elective rotations. Unlike physicians, who must complete a minimum of three years of residency after completion of medical schools, PAs are not required to complete such residencies. Despite this, there are residency programs in certain specialties for PAs who choose to continue formal education in such a format. A PA may use the post-nominal initials "PA", "PA-C", "APA-C", "RPA" or "RPA-C", where the "-C" indicates "Certified" and the "R" indicates "Registered." The "R" designation is unique to a few states, mainly in the Northeast; The "A" indicates completion of the Army Flight Surgeon Course. Most PAs use "PA-C". During training, PA students are designated PA-S. The use of "PA-C" is limited only to those PAs currently certified and in compliance with the regulations of the national certifying organization, the National Commission on Certification of Physician Assistants (NCCPA).

A graduate from an accredited PA program must pass the NCCPA-administered Physician Assistant National Certifying Exam (PANCE) before becoming a PA-C; this certification is required for licensure in all states. In addition, a PA must earn and log 100 Continuing Medical Education (CME) hours and reregister his or her certificate with the NCCPA every two years. Every six years, a PA must also recertify by successfully completing either the Physician Assistant National Recertifying Exam (PANRE) or Pathway II exam.

Scope of practice
PAs are advanced practice clinicians, and obtain medical histories, perform examinations and procedures, order treatments, diagnose illnesses, prescribe medication, order and interpret diagnostic tests, refer patients to specialists when appropriate and first-assist in surgery. They are employed in primary care or in specialties in urban or rural regions, as well as in academic programs. PAs may practice in any medical or surgical specialty, and have the ability to move to different medical and surgical fields during their careers.

PAs are licensed to practice medicine with physician supervision, which may be either in person, by telecommunication system or by other reliable means (for example, regular chart review and consultation). The physician supervision, in most cases, need not be direct or on-site, and many PAs practice in remote or underserved areas in satellite clinics.

All states, as well as the District of Columbia, Guam, the United States Virgin Islands, and the Commonwealth of the Northern Mariana Islands, have laws or regulations authorizing physician assistants to practice medicine. PAs may also prescribe medications in all of these locations; those who prescribe controlled medications in their scope of practice must also have a DEA number.

Employment
According to the AAPA, there were an estimated 68,124 PAs in clinical practice as of January 2008.

In the 2007 AAPA census, just over 56 percent of responding PAs worked in physicians' offices or clinics; 23 percent were employed by hospitals; and the remainder were employed in public health clinics, nursing homes, schools, prisons, home health care agencies, and the United States Department of Veterans Affairs. Approximately 9 percent of responding PAs provide health care to rural communities and those with fewer than 20,000 residents, in which physicians may be in limited supply.

The U.S. Department of Labor Bureau of Labor Statistics report on PAs states, "...Employment of physician assistants is expected to grow 27 percent from 2006 to 2016, much faster than the average for all occupations..." This is due to several factors, including an expanding health care industry, an aging baby-boomer population, concerns for cost containment, and newly-implemented restrictions to shorten physician resident work hours.

PAs in primary care practice can purchase $100,000-$300,000 insurance premiums for less than $600 a year. PAs malpractice coverage are higher in greater risk specialties.

Money Magazine, in conjunction with Salary.com, listed the PA profession as the "fifth best job in America" in May of 2006, based both on salary and job prospects, and on an anticipated 10-year job growth of 49.65%. According to the American Academy of Physician Assistants (AAPA), in 2007 the mean total income for physician assistants working at least 32 hours per week was $86,214. Physician assistants in dermatology or surgical subspecialties can earn $100,000-$200,000, with the mean total income for PAs working at least 32 hours per week in cardiovascular/cardiothoracic surgery listed as $104,681 for 2006.

In the U.S. Armed Forces and Uniformed Services
U.S. Army PAs typically serve as Medical Specialist Corps officers within Army combat or combat support battalions located in the continental US, Alaska, Hawaii and overseas. These include infantry, armor, cavalry, airborne, artillery and (if the PA qualifies) Special Forces units. They serve as the "front line" of Army medicine and along with combat medics are responsible for the total health care of soldiers assigned to their unit, as well as of their family members.

PAs also serve in the Air Force and Navy as clinical practitioners and aviation medicine specialists, as well as in the Coast Guard and Public Health Service. The skills required for these PAs are similar to that of their civilian colleagues, but additional training is provided in advanced casualty care, medical management of chemical injuries, aviation medicine as well as military medicine. In addition, military PAs are also required to meet the officer commissioning requirements and maintain the professional and physical readiness standards of their respective services.

Canada
The PA concept is being explored in Canada, where Canadian military PAs are gaining legislative changes allowing them to work in the civilian world after retirement. Education programs are now offered at the University of Manitoba in Winnipeg, McMaster University in Hamilton, Ontario, and the University of Toronto. Programs are 24 months in length.

England
In England, U.S.-trained PAs are working in a pilot project in Sandwell and West Birmingham. Education programs are now being offered by four universities: University of Birmingham, University of Wolverhampton, University of Hertfordshire (operating as Bedfordshire and Hertfordshire Postgraduate Medical School, in conjunction with the University of Bedfordshire), and St George's, University of London. The University of Warwick and University of Coventry have also explored offering these programs, but did not implement them due to a lack of need.

Also referred to as "Medical Care Practitioners", PAs are to be employed by the National Health Service. Though currently not a registered profession, PAs can currently practice under delegation rules. Programs are 24-36 months in length.

Scotland
Pilot projects in Scotland are underway, but no official educational programs have been implemented as of 2008.

The Netherlands
The Netherlands has educational programs at the Academie Gezondheidszorg in Utrecht, University of Arnhem/Nijmegen, the University of Groningen and the University of Leiden. Programs are 30 months in length.

South Africa
One program is now offered in South Africa, at the University of Witwatersrand.

Taiwan
In Taiwan, nurses can be trained to practice medicine in a 36-month program, being offered at the private Fooyin University.

Australia
Two educational programs in Australia are also planned to start in 2009, at the University of Queensland and James Cook University.