A Brief History of the Profession
The physician assistant (PA) role emerged over the last five decades due to the expanding demands of the medical field and to combat a shortage of doctors. The first PA program was started by Dr. Eugene Stead at Duke University in 1965 in recognition of the need for additional medical providers. He based the PA role on an existing relationship between a fellow physician and his assistant. Military corpsmen were some of the first PAs and were ideally suited to fill these positions once they completed their military duties, since they could continue to use their medical knowledge gained during military training and field work to serve the general public. Now, PAs are recognized physician extenders and are often viewed by patients as approachable and knowledgeable providers. The profession is beginning to stretch beyond U.S. borders to countries around the world.
A physician assistant is a mid-level provider who has received graduate level training and works under the supervision of a physician in virtually all medical specialties. The term supervision indicates the physician is the final decision-maker, but delegates the PA to function as a representative of the physician. The degree of supervision required may vary from state to state.
In Michigan there are five accredited physician assistant programs. While individual programs may have slightly different prerequisites, the student who wishes to be accepted to one of these programs should have a strong health science background, taking courses such as human anatomy and physiology, general chemistry, biochemistry, epidemiology, and statistics. Work experience involving some aspect of patient care or interaction is also generally necessary, with the number of hours needed dependent on each program, typically between five hundred and one thousand hours. I had the opportunity to work on third shift at an assisted living facility near my home while I was completing my prerequisites. I was responsible for the care of residents with mild to more advanced dementia and had to learn to handle emergencies, such as a heart attack in the middle of a night, falls, and delirium. I dispensed medications in the morning and assisted with ADLs (activities of daily living, such as bathing, dressing, feeding) for the residents. This group of people was special to me and I wanted to treat them as if they were one of my grandparents, taking extra time to look after them and to treat them with respect. This opportunity was helpful for me because it reinforced my desire to enter the healthcare field and it also taught me to appreciate the people who do the “hands on” work.
My decision to become a PA came to me gradually through a series of experiences and by realizing how I could use my affinity for Science and English in a vocation. After graduating high school I attended Hope College, which has a strong reputation for developing students in fields of pre-med, nursing, research, and education. I decided I wanted to pursue medicine and became interested in the PA profession after shadowing both physicians and PAs during one of my senior courses. Upon graduating from Hope I applied to Grand Valley State University’s PA program and was accepted.
Most PA programs are master’s level and are designed to structure the education model similarly to the training a physician receives in comparison to the nursing model. For example, as part of Advanced Human Anatomy and Physiology, the PA students take a human cadaver lab, one of my personal favorites because you can see how intricate the human body is created. PAs also receive extensive training in pharmacology (indications for medication, side effects, how they work) and pathophysiology (study of disease). Clinical rotations are performed after completing classroom courses and allow the PA student to experience a wide range of practices such as General Surgery, Cardiology, Family Practice, and Emergency Medicine; most programs also offer elective rotations for subspecialties. These rotations provide the opportunity to expand medical knowledge and skill sets, create professional connections, and guide the student to choose a field in which to practice. A master’s thesis or project may be required by individual programs.
The physician assistant field is regulated on state and national levels. This means that each state has different regulations to which a PA must subscribe. The state of Michigan allows PAs to have a broad scope of practice, and they can write prescriptions for almost all medications except those limited to certain physicians due to the type of medications, such as a limited group of pain medications that are restricted due to tendency for abuse. Physician assistants are required to take a national certification exam in order to obtain their license and recertify every six (soon to be ten) years. Although this process is not necessarily enjoyable, this requirement is important because it requires professionals to reinforce their knowledge base and stay up to date with current practice guidelines. Continuing medical education is another part of this recertification process, which necessitates 100 hours of documented education hours every 2 years. Education hours are gained by attending conferences, reading journal articles, proctoring students, giving lectures, etc.
Pros/Cons of the Occupation
One of the benefits of being a PA is flexibility to switch between specialties if desired, and to work in a variety of settings. For example, I could switch from a cardiology position to oncology to a surgical position during the course of my career. The background education a PA receives is comprehensive, and the PA is viewed as an individual who can be molded to the needs of the physician/practice. Subspecialty training is often gained “on the job” and sometimes through advanced training courses.
Also, I think it may be easier for PAs to balance work and home life than it is for a physician, depending on the type of position held. Due to high patient volumes and emergency situations I often work overtime, but my supervising physicians put in many hours more per week with meetings, emergency trips to the hospital during the night and 24 hour on-call responsibilities. This is more than I am willing to devote to a job because it can cause too much interference with church and family responsibilities. However, I think it is important for Christians to pursue an education and profession that allows them to support their families, church and Christian schools.
Another benefit of working under the supervision of a physician is that they provide medical malpractice coverage, which can be very costly. The practice I work for assumes responsibility for my actions, but I also maintain my scope of practice. This means that I perform my duties according to the limitations of my training and under the boundaries set by my attending physician(s). For example, as a cardiology PA I may order studies such as an echocardiogram, but I do not provide a formal impression on the results of this study, as it is the physician’s responsibility to interpret the test. I may explain what the results mean to the patient once I have the official report from the physician.
In my current position I have few responsibilities regarding the business aspect of medicine. The structure and maintenance of a medical practice requires a significant amount of attention. Although I could choose to own and run a medical practice (allowed by PAs in Michigan with supervision of a physician as indirectly as requiring only telephone contact) I currently have no desire to worry about the costs and decisions of maintaining a practice.
One of the disadvantages of my positions is that hospital-based medicine is 24/7 and 365 days a year. This requires work on the Sabbath day, and although it is a work of necessity, it may pull the Christian away from worship. The work can also be stressful and demanding. One must also be able to face situations where God’s rule over life and death is denied by a patient or family. Conversely, opportunities to witness are often encountered.
Responsibilities of the PA
As a PA student at Grand Valley State University I had the opportunity to participate in a clinical rotation at West Michigan Heart, a multi-specialty cardiology practice in Grand Rapids. I was surprised by how much I enjoyed this rotation, as I originally expected to join a pediatric practice or work in a surgical field once I completed my degree. The tempo of this rotation was fast paced and challenging, and I enjoyed the range of patients on this service.
A few months later I accepted a position with West Michigan Heart and started work as a hospital-based PA. Some of my responsibilities include assessing patients in the ER in consultation or for admission, preparing patients to go to the cardiac catheterization lab for procedures, answering emergency floor calls, and daily rounding on patients. I write prescriptions, order diagnostic and therapeutic studies, and interpret results of labs and tests. I may request a consultation from another specialty when required. At one point my shifts were divided between the hospital and the outpatient setting at West Michigan Heart’s main office, where I saw patients for post-hospital follow-up, emergency visits, and patients who received shocks from their implantable cardioverter defibrillators. As I gained clinical experience I gravitated toward the subspecialty of heart failure and became part of the Advanced Heart Failure team. These patients tend to be complicated with multiple medical problems often related to the decline of their hearts. I enjoy the problem solving aspect of my job and the challenge of performing patient assessment, assimilating data and formulating a plan.
About a year and a half ago I was asked to transition my role again and focus on heart transplant and mechanical cardiac support devices, temporary or long-term heart pumps that are implanted in the heart catheterization lab or surgically to support patients with severe cardiomyopathies (weak hearts). My official title is Ventricular Assist Device (VAD) Coordinator. It took me a couple of months to decide to accept this position as I worked through how I as a Christian could support this venture. How did I view heart transplantation? What about implantation of a long term heart pump in a patient who is 75 years old and failing due to progression of advanced heart failure? Is this a defiance of God’s plan or acceptable use of modern technology and medical advances?
As I worked through these challenging questions, I remembered that God has provided us the gift of medicine, and the advanced options that are available should always be weighed against his word. He has also taught us to look forward to our heavenly home where we will have a new life and body in him. Finally, we are called to rely on the Great Physician for healing and be content in his plan for our life and death. Keeping these principles in mind, I would like to share two brief examples of patients I have treated in my current role.
Almost a year ago I met a patient in his early 30s who was hospitalized for congestive heart failure. He was diagnosed with a cardiomyopathy about 6 months earlier and was suddenly struggling to live. Our team took him to the OR for emergency surgical placement of a left ventricular assist device (LVAD), a mechanical heart support device that would take over the majority of the pumping function of his heart. Several months later he developed recurrent heart failure despite adequate support from the VAD. He was placed at the top of our heart transplant list and within a month received his new heart. He is home with his wife and family and doing well.
The second example is a male patient in his mid-forties who had lymphoma as a teenager and had radiation therapy to his chest to kill the cancer. This left him with scarring in his lungs and heart and he subsequently developed a cardiomyopathy that did not significantly affect him until the last few years of his life. He was referred to our team due to rapid decline, and after much debate among the team it was decided he would have a temporary support device placed in the cardiac catherization lab to determine if his condition would improve over time with support from a device.
Interestingly, this patient’s father was an evangelical minister, and he and the rest of the family were waiting for what they called “a miracle of healing.” They described hope for a complete restoration of this man’s physical health. Despite the medical team’s advanced therapies and the family’s prayer for a “miracle,” the man continued to decline with progression of multi-organ failure over a 3 month course in the ICU. Up to the very end the family did not want to discuss the impending death of this man. This situation was difficult for me because I thought that as fellow Christians the family would rejoice that this man’s earthly suffering was drawing to a close and he would soon begin a new life in his heavenly home. While this was not the easiest opportunity for me to express my beliefs, there have been many circumstances that have allowed me to direct the patient and the family to comfort in Jesus Christ.
My job as a VAD Coordinator has been one of the most demanding and autonomous positions I’ve had as a PA. I see patients in clinic to evaluate their candidacy for a life support device, admit patients to the hospital, perform emergency evaluations for cardiogenic shock patients, troubleshoot device complications and manage patients in the ICU. I think I have the best of both worlds because I make clinical decisions for patients and often have more time than the physicians to work directly with them. The reward of providing compassionate care and helping critically ill patients recover and return to their daily life is a great joy.
My advice to the high school or college student is to pursue your education with your God-given strengths and abilities in mind. Research the field you are interested in, and if possible talk with or shadow someone in that profession to find out what is required and what they like or dislike about their position. There are a variety of opportunities in the health care field, from teaching to research to nursing to PA to physician. The professional men and women in our churches who represent these fields can motivate and support the young people to consider these occupations by speaking at career day, writing letters of recommendation, and providing a positive example of a Christian in a professional role. On a personal note, I encourage any additional questions regarding my job and appreciate the opportunity to share my story.