This article first appeared in the St. Louis Beacon, Oct. 31, 2011 - A car accident opened Paul Winter's eyes to his career choice. His dad was struck by a vehicle and was taken to St. Mary's hospital for treatment. There, the man Winter would remember as his dad's doctor turned out to be a physician assistant. Watching the medic go about his work made an impression on young Winter, so much so that he grew up to become a physician assistant, too.
Now, 23 years after completing his training, Winter is part of an occupation growing by leaps and bounds. The 700 PAs practicing in Missouri are among about 83,000 nationwide. The national number is expected to grow to more than 103,000 by 2018, according to industry figures.
Yet, plenty of Missourians still scratch their heads upon hearing health-care professionals identify themselves as physician assistants.
"We've been around for 40 years," Anne Garanzini says of the St. Louis University's physician assistant program, which she directs. "But there are people who still have not heard of us. People understand what doctors are and what nurses are, but they aren't quite sure what a physician assistant is."
PAs generally are mid-level medical professionals who work under the supervision of doctors and perform a number of general medical duties, including examining and counseling patients, treating some injuries and prescribing some drugs. They work in various medical specialties, including primary care, internal medicine, pediatrics, emergency medicine and surgery.
The PA system emerged as a profession during the Vietnam War era when veterans returned with lots of medical skills and no way to use them in civilian life. Students now undergo about 27 months of training beyond the bachelor's degree to obtain certification as a PA. The highest mean salary of $90,000 goes to those who specialize in emergency medicine. The lowest mean salary of $76,000 is for primary care.
A growing profession
The role of PAs is expected to grow partly due to health reforms and a shortage of family doctors to deliver care. The American Academy of Physician Assistants believes PAs could help address the shortage, notes Dr. Stephen Dodge, director of the PA program at Missouri State University in Springfield. He says to expect a shortage of primary-care doctor shortage "if we stick with our current model" of not making full use of PAs to supplement services provided by physicians.
"It would be more effective, more efficient if we changed the model so that each primary-care physician we have is able to take care of more patients by utilizing mid-level providers to do some of the work. It certainly would be a lot easier and less expensive to train mid-level providers than it would be to train physicians."
Missouri State's program admits 28 students a year, and SLU accepts 34. It's a competitive process, Garanzini notes, saying between 400 to 700 applicants apply for the 34 slots. Given the popularity of the programs and the growing demand for PAs, it would seem logical for the two universities to expand to accommodate more applicants. Logical, Garanzini says, but impractical. In addition to in-class studies, each student must do clinical work.
"It would be hard to find enough clinical sites to place (additional) students," she says. "We're competing with medical schools at St. Louis University and Washington University. We probably need to open up more programs or open up more slots within the programs, but we also have to keep the quality up, too."
Ann Davis, senior director of state advocacy at the American Academy of Physician Assistants, expects the role of PAs to grow as states like Missouri move to what's called a health-home model of delivering patient care. It requires more coordination among everyone responsible for a patient's care.
"This will involve increased utilization of physician assistants," she says. "Patients being seen for a chronic kidney disease, for example, certainly need a physician's care, but not necessarily for every visit. Physician assistants can help to make sure the labs are done, the patient is stable, blood pressure is good and the patient knows what to do in terms of self-management. It's that coordination part and extending access with the right mix of providers that will make a difference."
SLU's Garanzini also suggests that that PAs might offer part of the answer in addressing shortages of health-care providers in some cities. "There are some programs realizing that we need to pull people form these communities and train them as physician assistants and have them work back in the communities," she says.
Regulations hamper profession's growth
Winter, who was inspired to become a PA after a car struck his father, grew up in Normandy and got his training at SLU. He practices at Missouri Baptist Hospital in west county, enjoys his job, but feels there is room for change in Missouri's regulations of PAs.
In particular, he thinks Missouri should change its rule regarding the amount of on-site supervision a PA must receive, calling the rule inefficient.
"The way the Missouri law is written, the physician has to be present 66 percent of the time," he says, adding that getting a waiver to that rule is tough even in communities and sections of the state with a shortage of health-care providers.
On the other hand, he says that nurse practitioners work in a less restrictive environment, requiring on-site supervision only once every two weeks.
"It becomes a difficult climate for us because that law is more restrictive than it is for another mid-level practitioner who has similar training but performs in a much more relaxed supervisory requirement."
Still, he says his work is gratifying. A couple of years ago, he says he was at a meeting in California and ran into the very PA who had treated his dad years earlier.
"I went up to him and told him about the time he treated my dad. He was able to do a lot of what a physician did. I thought, 'Wow this is something!' I was proud to tell him that he had inspired me."
Funding for the Beacon's health reporting is provided in part by the Missouri Foundation for Health, a philanthropic organization that aims to improve the health of the people in the communities it serves.
