State laws mandate that physician assistants (PAs) be supervised by a licensed physician, but the specific terms and stipulations of supervision vary among state or federal statutes and regulations. Because supervision of PA practice by physicians is a dynamic process, task delegation patterns may evolve over time as PAs gain more experience working with physicians. This, in turn, may result in less physician time spent supervising the PA and the PA assuming greater degrees of responsibility in the performance of clinical activities. Medical sociologists have labeled this progression of clinical duties “negotiated performance autonomy” and suggest that it is an ideal descriptor of the PA-physician dyad in clinical practice.1
METHODS AND ASSUMPTIONS
This study examined the degree of physician supervision reported by practicing PAs in various specialties. Data were drawn from the 2013 AAPA Annual Survey, a web-administered national cross-sectional survey conducted by the American Academy of Physician Assistants.2 The survey was sent via e-mail link to 87,907 PAs assumed to be in active clinical practice in September 2013; reminders were sent in subsequent weeks. Responses to the survey resulted in a sample of 17,924 PAs in active clinical practice, a response rate of 20.3%. Results of the survey were compared with findings from other national survey reports and sample surveys of practicing PAs, and were found to be quite similar, particularly in the areas of demographic characteristics, practice setting, and specialty.3,4 For the purposes of this report:
- Primary care includes family medicine without urgent care, family medicine with urgent care, general pediatrics, and general internal medicine.
- Consultation was defined as physician-PA interaction.
- Nonclinically practicing PAs, those primarily employed in nonclinical work such as education or administration, were excluded.
The proportion of PAs who reported spending less than 10% of time consulting was expected to increase over time. Respondents who had not changed their employer were asked to estimate the amount of clinical time spent consulting with the physician. We plotted the percentage of PAs who spent less than 10% of their time consulting with the physician with the length of time in clinical practice (Figure 1) over time in practice.
The number of PAs who spent less than 10% of their time consulting with the physician based on their experience is shown in Figure 1. PAs with 15 or more years experience were more likely to report spending 10% of their time consulting with the physician compared with those with 0 to 14 years of experience (P<0.001).
The plot line drawn in Figure 1, showing PAs who worked with the same physician over their careers, suggests that the percentage of PAs who reported spending less than 10% of their time consulting with the physician increased with length of time in practice.
Among all specialties, primary care stood out as the specialty with the highest levels of self-reported practice autonomy. The curves of the relationship of the percentage of PAs spending less than 10% of their time consulting with the physician revealed patterns that were similar to the one observed in primary care in some specialties (emergency medicine, other specialties), but less so in others (internal medicine subspecialties, surgical subspecialties, Figure 2). Levels of supervision appear to be inversely related to length of time in practice in primary care. In most specialties, the number of PAs who practice with small amounts of supervision appears to increase with time in practice, especially during the first decades of practice.
The principal limitation of this study is the relatively low response rate to the 2013 AAPA survey. Additional limitations include the inability to draw cause-effect relationships (due to the nature of cross-sectional studies), potential bias in the reporting of estimates of physician time spent in consultation, and bias inherent in investigations depending on self-reported information.
The observation that PAs report less time consulting with physicians as they gain more experience working in that physician's practice suggests that physicians appear to develop increasing levels of trust with their PAs as they work together over time. Demonstration of this association may hold important economic and clinical implications for practices employing PAs, particularly those in primary care. PAs who consult with their supervising physician less than 10% of the time are attaining a degree of practice autonomy that could be related to length of time in practice. Over time, PAs may assume a greater degree of autonomy in clinical practice activities (see “Is physician assistant autonomy inevitable?” on page 18 in this issue). Practice autonomy in primary care has been authorized for PAs who practice in closed healthcare systems such as the Veterans Administration.5 Given the increasing demand for primary care services, knowing that PAs working with physicians in primary care tend to steadily grow in autonomy may permit those practices to maximize their clinical efficiency (output) as well as contain salary costs. From a workforce policy viewpoint, this finding would support using more PAs in primary care to fill gaps in the supply of primary care physicians. The PA profession is seeking to redefine the nature of the relationship between PAs and their employing physicians, as witnessed by the AAPA House of Delegates recent resolution to change the term defining the PA-physician relationship from “supervision” to “collaboration.” Knowing that a substantial degree of practice autonomy is already granted to practicing PAs by physicians as they gain more experience substantiates this policy direction.
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2. American Academy of Physician Assistants. The 2013 Survey of Practicing Physician Assistants
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