Postgraduate education for physician assistants was introduced in 1973 at Montefiore Medical Center to offset shortages in medical and surgical house officer labor.1 Over the years, a number of programs developed, and by 2012, there were 60 postgraduate programs for PAs (http://www.appap.org). Most programs are small and, in the aggregate, produce only a hundred or so graduates annually.2 In spite of 4 decades of postgraduate experience and a certification process, remarkably little is known about the details of this postgraduate education strategy for PAs.1,3 To address this knowledge gap, an administrative study of advanced rheumatology training was undertaken.
Rheumatology is a subspecialty of internal medicine with increasing shortages and a poor outlook for increasing the supply of providers.4 Other factors in the increasing demand for rheumatologists are a limited number of physician fellowships, an aging workforce, and lifestyle changes. Since the mid-1970s, rheumatologists have turned to PAs and nurse practitioners to offset some of their clinical work.5 The number of PAs in rheumatology, what they do, and their role is slowly being revealed.6 For the most part, PAs in rheumatology are informally trained and work in diverse settings.7
The University of Texas Southwestern (UTSW) Medical Center PA rheumatology fellowship was inaugurated in 2004 as a 12-month postgraduate program. The Veterans Health Administration (VHA) underwrote the pilot study and the UTSW Division of Rheumatic Diseases administered the funds and oversaw the education of the PAs. The PA fellow was assigned the same role as a first-year rheumatology medical officer fellow and also the same schedule to maximize exposure to a variety of patients and educational opportunities (Table 1). This mix produced three first-year medical officer clinical fellows and one PA fellow; all four shared inpatient and outpatient consultation responsibilities. The majority of patient exposure was at the VA Medical Center in Dallas and the UTSW hospital or clinic.
Patient experience and education The PA fellow was responsible for outpatient and inpatient consultations. Each week, the PA was also assigned to 4 half-day outpatient VHA clinics, a full day of specialty rotations such as pediatric rheumatology, orthopedics, rehabilitation, radiology, elective specialties, and rotation through a private practice clinic. Formal educational experience included immunology (60 classroom hours), rheumatology grand rounds, rheumatology journal club, a research project, as well as weekday and weekend rheumatology conferences. Didactic lectures totaled over 80 hours per year. Four hours of midday conferences occurred throughout the week and provided additional basic science, pathology, and clinical medicine education.
To better understand the role of the rheumatology fellowship, an administrative study was undertaken. The PA fellow maintained a log of patients, procedures, and other activities that was complemented through electronic medical record review and verified by administrative records, interviews, and chart audits.
On average each fellow was the principal clinician for 534 rheumatology patients—58 inpatients and 476 outpatients (Table 2). The PA averaged three patients per clinic session (half day) with a range of two to six. A primary diagnosis was recorded for each visit and analyzed at the end of the fellowship year (Figure 1).
In this PA postgraduate training, most patients were adults (median age 66 years), and male (91%). On average, the VHA rheumatology patient had three significant comorbidities often involving the heart, lung, liver, kidney, or bone.8 In addition to medical conditions, many VHA beneficiaries had significant psychiatric diseases such as schizophrenia, addiction, posttraumatic stress disorder, and depression. Some of the more vulnerable and fragile patients needed coordination with other medical services and their comorbidities required heightened awareness of treatment complications. The ability to manage complex diseases highly concentrated in one setting, in a fully computerized vertically integrated health care system, provided a rich foundation for polyclinic care and experience with challenging patients.
Upon completion of the fellowship, each graduate secured a position in a rheumatology practice. All had employment offers with competitive salaries before completing the fellowship, suggesting a demand for their skills.6 All four graduates endorsed the fellowship as worthwhile. After 4 years, the pilot study was concluded; no additional funds were made available to continue the fellowship.
A yearlong PA rheumatology fellowship, developed jointly by UTSW and the VHA, was diverse in exposure to patients. Under the structure of the VHA, an opportunity was afforded for PAs to gain broad-based rheumatology experience within a concentrated period of time. Although the fellowship training was intense, it remained in the true tradition of apprenticeship, where the preceptor instructs the protégé in how to approach the patient and use available tools for diagnosis and treatment. Trainees, staff, and faculty viewed this PA fellowship as valuable; the VHA acknowledged the trainees as a source of additional labor in providing access to medical services. Alternative strategies to develop trained and capable rheumatology PAs should be assessed and compared.
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© 2013 American Academy of Physician Assistants.
8. Oliver A. The Veterans Health Administration: an American success story. Milbank Q