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Commentaries on health services research

Bushardt, Reamer L., PharmD, PA-C, DFAAPA; Cawley, James F., MPH, PA-C; Dehn, Richard W., MPA, PA-C, DFAAPA

Journal of the American Academy of PAs: May 2018 - Volume 31 - Issue 5 - p 1–2
doi: 10.1097/01.JAA.0000532131.45907.4e

Reamer L. Bushardt is professor and senior associate dean at the George Washington University School of Medicine and Health Sciences in Washington, D.C., a clinical, translational scientist in the Children's National Health System in Washington, D.C., and editor-in-chief of JAAPA. James F. Cawley is professor of prevention and community health and professor of physician assistant studies at the George Washington University in Washington, D.C. Richard W. Dehn is a professor in the College of Health and Human Services at Northern Arizona University's Phoenix Biomedical Campus and a professor in the Department of Biomedical Informatics at the University of Arizona College of Medicine in Phoenix. The authors have disclosed no potential conflicts of interest, financial or otherwise.

Richard W. Dehn, MPA, PA, DFAAPA; Roderick S. Hooker, PhD, PA; and James F. Cawley, MPH, PA-C, department editors

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Differences in patient care: Physician vs. PA/physician model


Medical care for hospitalized patients is increasingly allocated to PAs, yet there is limited evidence about the quality and safety of care. In a multicenter matched-controlled study, the traditional model in which only physicians are employed for inpatient care was compared with a mixed model employing physicians and PAs. Patients were followed from admission until 1 month after discharge. The primary outcome measure was patient length of stay (LOS). Secondary outcomes concerned 11 indicators for quality and safety of inpatient care and patients' experiences with the provided care. Data on 2,307 patients from 34 hospital units were analyzed. The involvement of PAs was not significantly associated with LOS. None of the indicators for quality and safety of care were different between the two study arms. However, the involvement of PAs was associated with better patient experiences. No differences in LOS and quality of care were found between units on which PAs, in collaboration with physicians, provided medical care for the admitted patients, and units on which only physicians provided medical care. Employing PAs seems to lead to better inpatient experiences.1

Commentary by Reamer L. Bushardt: There is a lot to like about the design and implementation of this comparative efficacy study. A multicenter trial, it evaluated various inpatient medical specialties and hospital types, and tackled two features of healthcare's triple aim. Two important strengths of the study are high response rates on all patient surveys and the intent-to-treat approach for all analyses. The authors compared physician-PA team care to physician-only care and found equivocal findings in patient LOS, quality, and safety. Collaborative care involving PAs also was associated with improved patient experience in each category surveyed (communication, continuity, cooperation, and medical care). Interestingly, physician-PA teams had significantly lower workloads at the unit (in minutes/bed/week) and more urgent admissions than the physician-only group. The study is arguably generalizable to Dutch hospitals but not to the United States. PA education in the Netherlands embraces a unique workplace-based training model with graduates frequently hired by the same sites where they trained. This phenomenon may be influential to the trial's results, including improved patient experience. If I could offer one bit of constructive criticism to the authors, it would be to forgo calling a PA a nonphysician provider in future reports. Nobody likes to be defined by what they are not.

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1. Timmermans MJC, van Vught AJAH, Peters YAS, et al The impact of the implementation of physician assistants in inpatient care: a multicenter matched-controlled study. PLoS One, 2017;12(8):e0178212.

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Literature review of PA and NP satisfaction


Examining the work-related psychologic states of PAs and NPs is important, given their role expansion. The guided review was used to examine studies published between 2000 and 2016 and included features of the research to draw conclusions about overall quality. Applying theories in job enrichment and job demands, articles were identified that contained analyses of satisfaction, burnout, stress, and turnover. Key findings include the lack of robust research designs, overemphasis on job satisfaction, lower levels of satisfaction across both groups, and higher intrinsic versus extrinsic satisfaction levels generally. The literature can develop by using larger, more representative samples, including subgroup analyses that incorporate everyday work contexts, and more predictive modeling. The results suggest that both occupations experience role expansion in both positive and negative ways that may require additional policy or managerial interventions.1

Commentary by James F. Cawley: A premise of this examination of the literature on PA and NP job and career satisfaction and related issues is that it is important to explore whether PAs and NPs are “psychologically adjusted in favorable ways” to their roles and workplace circumstances, especially if a goal is to place them more at the center of direct patient care delivery. Noted is the finding that most studies of job satisfaction show somewhat lower levels, a finding that is debatable in the PA world where national AAPA surveys have shown just the opposite. Some levels of burnout have been observed among PAs and NPs but often this is specialty-specific. One reason to be a bit skeptical about observed levels of job satisfaction and burnout among these professionals is the steady rise in salaries and the strong demand for their services in the medical marketplace. Occupations that enjoy such positive circumstances would likely have less stress, burnout, and job dissatisfaction. As noted by the authors, higher-quality studies are needed of the work-related psychologic states of PAs and NPs. Additionally, the studies should not collectively examine PAs and NPs, as these professions have important educational, practice, and professional differences that could influence responses to survey questions related to work-related psychologic states.

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1. Hoff T, Carabetta S, Collinson GE. Satisfaction, burnout, and turnover among nurse practitioners and physician assistants: a review of the empirical literature. Med Care Res Rev. [e-pub Sep. 1, 2017.]

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Burnout—An emerging risk or an unrecognized occupational hazard?


High levels of burnout have been found throughout many healthcare professions. Burnout has been described in PAs working in the ED but not critical care medicine. A survey of PAs in critical care medicine used the 22-question Maslach Burnout Inventory, a validated tool comprising three subscales—emotional exhaustion, depersonalization, and achievement. Multivariate regression identified factors independently associated with severe burnout on at least one subscale, higher burnout scores on each subscale, and the total inventory. From 431 PAs invited, 135 (31.3%) responded. Severe burnout was noted on at least one subscale in 55.6% of respondents—10% on the “exhaustion” subscale, 44% on the “depersonalization” subscale, and 26% on the “achievement” subscale. After multivariable adjustment, caring for fewer patients per shift (comparing providers who care for 1 to 5 versus 6 to 10 patients per shift), and rarely providing futile care versus providing futile care often were associated with less severe burnout on at least one subscale. Those caring for 1 to 5 patients per shift and those providing futile care rarely also had a lower depersonalization scores. Job satisfaction was independently associated with having less exhaustion, less depersonalization, a greater sense of personal achievement, and a lower overall burnout score. Severe burnout is common in PAs in critical care.1

Commentary by Richard W. Dehn: Burnout in healthcare professionals is well documented. A systematic review found that in ICU personnel, the overall prevalence of burnout was as high as 61%.2 Other researchers have investigated PA burnout in other specialties and found it surprisingly high.3-5 Documentation of burnout in PAs conflicts with a common assumption about the profession—that PAs really like being PAs. In fact, high PA career satisfaction has been observed over decades.5-7 However, very little is known about job burnout in the PA profession. For example, we do not know the extent of PA burnout overall, whether PA burnout is unique to specific practice settings, or whether the prevalence of PA burnout is changing over time. Advanced research is needed to measure PA burnout in multiple clinical settings, whether it is increasing, whether it is related to the increasing corporatization of the American healthcare delivery systems or other structural factors, and whether there are factors associated with burnout that are unique to PAs. It is easy to assume that because PA career satisfaction has historically been high, that burnout is not a significant problem in the profession. Could job burnout be a warning sign of decreasing career satisfaction for PAs?

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1. Bhatt M, Lizano D, Carlese A, et al Severe burnout is common among critical care physician assistants. Crit Care Med. 2017;45(11):1900–1906.

2. Chuang CH, Tseng PC, Lin CY, et al Burnout in the intensive care unit professionals: a systematic review. Medicine (Baltimore). 2016;95(50):e5629.

3. Benson MA, Peterson T, Salazar L, et al Burnout in rural physician assistants: an initial study. J Physician Assist Educ. 2016;27(2):81–83.

4. Bell RB, Davison M, Sefcik D. A first survey. Measuring burnout in emergency medicine physician assistants. JAAPA. 2002;15(3):40–52.

5. Hooker RS, Kuilman L, Everett CM. Physician assistant job satisfaction: a narrative review of empirical research. J Physician Assist Educ. 2015;26(4):176–186.

6. Marvelle K, Kraditor K. Do PAs in clinical practice find their work satisfying. JAAPA. 1999;12(11):43–47.

7. LaBarbera DM. Physician assistant vocational satisfaction. JAAPA. 2004;17(10):34–40.

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