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Missing the mark: Why is some research on PAs just wrong?

Dehn, Richard W. MPA, PA-C, DFAAPA

Journal of the American Academy of PAs: December 2014 - Volume 27 - Issue 12 - p 9
doi: 10.1097/01.JAA.0000456578.54756.0c

Richard W. Dehn is a professor in the College of Health and Human Services at Northern Arizona University's Phoenix Biomedical Campus, and chair of the university's Department of Physician Assistant Studies. The author has disclosed no potential conflicts of interest, financial or otherwise.



If you read healthcare workforce research that is published in journals outside our profession, you will inevitably find articles in which the findings appear to have little relationship to the clinical world we see in our jobs as PAs. At times, these articles are published in prestigious journals by researchers with impressive bylines. So, how do works that purport results so clearly disconnected from the actual practice environment get published?

A recent example of this type of disconnected publication describes an analysis of the 2012 Medicare physician/supplier procedure summary master file, focusing on dermatologic procedures billed by PAs or NPs using their National Provider Identifier (NPI).1 The authors spotlight the large number of such procedures performed by PAs and NPs, concluding that most of these procedures were performed by inadequately trained providers practicing independently. So many logical steps are missing between the hypothesis and conclusion—too many to cover in this brief commentary, but I invite you to read the article and make your own critical appraisal.

I wish I could say that this was an uncommon or occasional phenomenon. Regrettably, it is not so uncommon. Just a cursory glance through a year's worth of published workforce articles reporting on PAs brought a few other disconnected pieces to the surface. One of the most memorable is an article describing a model in which provider ratios were defined that would, in theory, adequately provide medical care to a defined population. Under this model, if the population of the United States could be proportioned in such a fashion, practicing physicians, PAs, and NPs could meet the current healthcare workforce demands.2 This article was reviewed in JAAPA's Citations department.3 This second example offers little resemblance to the practice world most of us experience. Are the authors simply not aware that their conclusions deviate from general perceptions? Are they attempting to be provocative?

A third example is a study of PAs and NPs in Mayo primary practices, which sought to determine if their contribution to patient care was complementary or substitutional.4 I was bewildered reading this piece. I asked myself whether the authors had even a modest appreciation for what PAs and NPs do in primary care practices that use physicians, PAs, and NPs. This article also was critiqued in JAAPA's Citations department.5

How can pieces describing PAs be published in reputable journals when authors so grossly misunderstand what PAs actually do in clinical practice? Take a look at the bylines for the three examples I just described; none of the authors are PAs. One possibility is that none of these authors actually know much, or anything, about what PAs really do in practice. Would any of these three pieces have survived peer review if a PA, physician, or another professional highly knowledgeable in PA practice was invited to offer a critique?

One strategy to ensure a higher quality peer review process could be to encourage researchers performing workforce projects that involve PAs to include a PA researcher on the team. Few PAs are trained in research, which may be the primary reason why PAs are not part of many research teams.6

PAs are frequently misrepresented and misunderstood by health workforce researchers, likely because we do not have enough PA researchers or journal peer reviewers. Our educational system is not structured to encourage the development of researchers among graduates or faculty, so the relative number of PA researchers is unlikely to increase anytime soon. Our profession badly needs representation among the research ranks. How can we get there?

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1. Coldiron B, Ratnarathorn M. Scope of physician procedures independently billed by mid-level providers in the office setting. JAMA Dermatol. [e-pub Aug. 11, 2014].
2. Green LV, Savin S, Lu Y. Primary care physician shortages could be eliminated through use of teams, nonphysicians, and electronic communication. Health Aff (Millwood). 2013;32(1):11–19.
3. Hooker RS, Dehn RW. Commentaries on health services research. JAAPA. 2013;26(9):60–61.
4. Rohrer JE, Angstman KB, Garrison GM, et al. Nurse practitioners and physician assistants are complements to family medicine physicians. Popul Health Manag. 2013;16(4):242–245.
5. Everett CM, Hooker RS, Dehn RW. Commentaries on health services research. JAAPA. 2014;27(2):54–55.
6. Ritsema TS, Cawley JF. Building a research culture in physician assistant education. J Physician Assist Educ. 2014;25(2):11–14.
© 2014 American Academy of Physician Assistants.