The physician assistant (PA) designation in the United States dates to the mid-1960s, yet the profession has perhaps never been as robust as it is today. Once intended only for primary care physicians, PAs are now the norm in medical specialties. Accredited educational programs and on-the-job training equip these medical professionals to master specialty-specific skills and tasks, making them invaluable to an otolaryngology practice.
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March 2023“In a world where the physician shortage is increasing and reimbursement is declining, while the cost of providing care rises annually, PAs represent an excellent opportunity to provide quality clinical patient care in a cost-effective manner, improving patient access to otolaryngology while providing ancillary revenue and profitability to an otolaryngology practice,” explained Gavin Setzen, MD, at Albany ENT and Allergy Services in New York.
As Dr. Setzen pointed out, about 300 otolaryngology residents and fellows graduate per year nationwide. Meanwhile, rates of physician burnout and retirement grow, and demand for otolaryngology care outpaces supply. Otolaryngologists who have successfully integrated PAs into their practices say it’s one of the best decisions they have ever made.
Establishing a successful physician–PA partnership, however, requires care and preparation. The goal is to maximize the individual PA’s potential and value in the otolaryngological setting, optimizing the quality of care and workplace efficiency while growing revenue.
Best of Both Worlds
Driven and talented, PAs often feel that they have gotten the best of both worlds in their line of work. The following PAs’ credentials are a testament to the talent and dedication they bring to the table.
I was trained to be an extension of my supervising physicians’ abilities so that their time is freed for the most challenging cases. There is no part of PA leadership that is attempting to achieve independence from physicians. —Lorin Catalena, MS, PA-C
Passionate about science since high school, Lorin Catalena, MS, PA-C, wanted to enjoy a balanced life that fully served career and family. After obtaining her nutritional sciences degree, Catalena opted for the rigorous PA program at Baylor College of Medicine in Houston. She has worked as a PA for 23 years. Since 2005, she has been with Texas ENT & Allergy in College Station, where she sees acute and chronic illnesses and has a special focus on voice disorders and videostroboscopy. She also teaches physical exam and patient documentation skills to medical and graduate students at Texas A&M University, also in College Station. “The PA profession allowed me the rigor of a medical degree and an avenue for seeing patients and engaging in direct treatment planning, while leaving me time to be fully engaged in my family as well,” she said.
Similarly, Kerry S. Camp, PA-C, found her happy medium in the PA life. “I went the premed route in undergrad because I’d always been fascinated by human physiology and medicine but realized junior year that I was neglecting some of my passions, like running, horseback riding, and spending time with friends and family, to maintain the grades necessary to get into a top-tier medical school,” she said. “After some soul-searching, I realized I might be able to have it all and deliver healthcare as a PA without the traditional insane 80- to 90-hour weeks required of a surgeon. For me, a PA career has been a really nice fit.” Camp worked her way through the Yale School of Medicine Physician Associate Program and now practices at the Facial Plastic and Reconstructive Surgery Center and the Facial Nerve Center at Massachusetts Eye and Ear in Boston.
Paige Williams, PA-C, felt the pull toward a medical career from age 17. “The opportunity to physically help people who were in pain and provide compassion at those vulnerable moments was what the Lord wanted for me,” she said. On a practical note, she added, “The responsibilities of being a PA-C fit the scope of practice I was looking for and provided flexibility for additional specialty training.” Today, Williams is the lead advanced practice provider (APP) in the outpatient private otolaryngology practice for ENT and Allergy Centers of Texas in McKinney. “My role includes 70% outpatient clinic with my own patient schedule, 20% operating room first assist, and 10% on-call with inpatient and emergency room consults,” she said.
Educational Programs
The typical PA educational program lasts 2½ to 3 years. “The curriculum is fast paced, rigorous, and based on a medical degree model of training,” said Catalena. “PA students attend classes full time, and courses include anatomy with cadavers, physiology, pharmacology, research, organic chemistry, physical exam skills, documentation, and all systems’ disease processes. Following curriculum completion, PA students begin their inpatient and outpatient rotations. A master’s thesis is completed as well.” Rotations for future PAs typically include all the core clinical settings plus a choice of electives.
Programs like Baylor’s have PA and medical school students learning and working together, which Catalena sees as a great advantage to both groups. “Future physicians can see the intensity of the PA curriculum and the competency and confidence of PA students firsthand. This often fosters a bond between the two, which is excellent for future teambuilding,” she said. “I was trained to be an extension of my supervising physicians’ abilities so that their time is freed for the most challenging cases. There is no part of PA leadership that is attempting to achieve independence from physicians.”
After graduating from PA school, students take the Physician Assistant National Certifying Exam, or PANCE. As certified PAs, they are required to take a recertifying exam every 10 years and show proof of 100 hours of continuing education every two years. The National Commission on Certification of Physician Assistants is the only certification board for PAs in the country, while state medical boards license PAs. (The American Academy of Physician Associates (AAPA) lists information on individual state licensing boards on its website (https://www.aapa.org/advocacy-central/state-advocacy/state-licensing/list-of-licensing-boards/)).
A rigorous accreditation process reinforces standards of excellence and commonality in PA educational programs. Only students who have gone through an accredited program can sit for the PANCE exam. The Accreditation Review Commission on Education for the Physician Assistant currently recognizes 300 accredited U.S. PA programs with continued, provisional, or probationary status.
Unfortunately, there are still too few PA programs to keep up with demand. “The competition to gain acceptance into these programs can be fierce,” said Dr. Setzen. “There should be an increase in the number of PA programs and positions available, as well as an expansion of the types of educational institutions offering PA programs, including both medical and surgical subspecialty training.” He would like to see an expansion of the types of institutions offering PA programs, including subspecialty training, as well as more hands-on training earlier in the program and more technology-based training.
PA Integration Models
An otolaryngology PA’s role depends on the specific needs and preferences of the practice, explained Dr. Setzen. “Some practices may be able to function effectively without PAs,” he said. “In other cases, otolaryngologists may prefer to have PAs help manage the workload and improve patient care, either by working alongside an individual otolaryngologist or separately.” In the latter example, the PA sees patients independently in a physician-led, team-based model. “This model can vary in both academic/employed systems and in private practice and can be tailored to the specific needs of the otolaryngology group,” said Dr. Setzen.
Scott P. Stringer, MD, MS, is one of 15 otolaryngologists partnered with three PAs and seven nurse practitioners (NPs), categorized together as advanced practice providers (APPs), at the University of Mississippi Medical Center in Jackson. “The APPs see inpatient consults and run some independent clinics where they see some less complex patients, which frees up the physicians for other work,” said Dr. Stringer. “We also have them see postoperative patients.” When working in conjunction with physicians, the APPs do much of the pre- and post-visit work.
APPs allow a physician to focus on high-return areas like procedures in the clinics and generating surgeries … while the APP works on things that may be more time-intense but potentially not as financially rewarding for the practice. —Scott P. Stringer, MD
The otolaryngology department at Ochsner Health in Covington, La., currently has 30 surgeons and approximately 10 APPs (50/50 PAs and NPs), reports John Carter, MD, a pediatric otolaryngologist and the department’s chair. “In pediatric otolaryngology, our APPs see their own schedule of patients who have relatively routine problems,” he explained. “They help identify patients who need surgery, and they see some postop patients.” Although the APPs operate independently in a clinic, a physician provider is always there to answer questions or supply a second opinion. The practice also subspecializes APPs in areas such as sinus and allergy, facial plastics, pediatric ear, and head and neck cancer, among others. “It’s sometimes easier with this model because they don’t necessarily have to learn the entire breadth of otolaryngology, and they can focus in during their training period,” Dr. Carter said.
On-the-Job Training
One way to ensure a successful PA partnership is to provide training for the first few months of employment. At Ochsner Health, incoming PAs participate in a six-month program. During this time, those who plan to subspecialize spend most of their time with these specific provider types. “If they’re going to be comprehensive, however, they get to rotate through all the subspecialties,” Dr. Carter said, adding that PAs train at the specific geographic location at which they are going to work so they’re used to those providers’ practice patterns and preferences. The program includes weekly lectures and corresponding literature. During this period, trainees aren’t expected to do any billable work, but they are paid a salary.
Albany ENT and Allergy Services has established a structured yet flexible 24-week program for its incoming PAs in which the newcomers primarily shadow physicians and learn practice procedure and otolaryngology examination-specific techniques for the first nine weeks. By week 10, they begin to take on their own patient schedule that increases incrementally each week. By week 25, the PA is on a full 20 patient-per-day schedule. Dr. Setzen stressed, however, that the learning process is ongoing and that physicians must be committed to the success of PA partnerships for the long term. “It’s incumbent upon the practice’s physician leadership to maintain oversight of the PA team, provide continual education and training, and always be available to consult with PA colleagues in real time,” he said.
Taking on staff PAs costs time and money, and on-the-job training is a way to protect this investment and ensure its success. “Even though they trained in a general program, a brand-new PA out of residency still needs a ramp-up period to work in an otolaryngology practice,” noted Dr. Stringer. “You must invest time to teach them, engage them in the practice, introduce them to referring physicians, and let your patients know about them. You don’t just wind them up, stick them in the practice, and everything is fine. You need to make an upfront investment.”
Financially, most practices can or do ultimately benefit from having PAs on staff. “The effort that’s required to see enough patients to bring in the revenue needed to cover overhead costs and salaries is growing, and the regulatory burden is increasing as well,” pointed out Dr. Stringer. “APPs allow a physician to focus on high-return areas like procedures in the clinics and generating surgeries, which returns a higher amount per unit of time, while the APP works on things that may be more time-intense but potentially not as financially rewarding for the practice, such as removing earwax or seeing someone for a cold.”
A Means to an End
Whether an otolaryngological practice has a single PA or a team of 20, the goal is the same: to integrate these medical professionals into the daily business of caring for patients with a wide variety of needs. A properly trained PA can solve many challenges for a practice—once you’ve identified them. “You need to know where your bottlenecks are,” said Dr. Carter. “If your bottleneck is patient access, for example, your goal is to see more patients, and PAs are very helpful in expanding patient access. Similarly, if you’re struggling with surgical conversion rates, a PA can by help by managing more of your nonsurgical or pre- and postop visits.”
Most patients are acclimated to seeing APPs for routine visits and may even prefer it if it means getting in to see someone sooner; however, it isn’t a good idea to make assumptions about a patient’s needs. “If an otolaryngologist refers a patient to me who has had nine prior surgeries, they want me to see that person,” said Dr. Stringer. “In general, though, make sure that you’ve educated patients about the role of the PA in your practice, and [explain] that the PA has a good understanding of when the physician needs to be involved.”
Our relationship is full of trust and good communication that’s built on a strong foundation of training and a willingness to come together as a team. —Paige Williams, PA-C
Dr. Setzen reports that PAs at his practice receive favorable feedback in patient surveys. “Our walk-in ENT Urgent Care Clinic is staffed by PAs with physician oversight, which provides superb access and care to dozens of patients every day,” he said, noting that many of his practice’s patients preferentially seek out “their” PA.
There is some resistance in the medical community to the expanding role of APPs, some of it based around fears that they would infringe on physicians’ practices and perhaps even attempt to provide care beyond the scope of their knowledge, skill, and training. Such concerns may be behind the current debate around the appropriate official title for these professionals. In spring 2021, the AAPA passed a resolution to change the title of “physician assistant” to “physician associate.” However, the American Medical Association and other physician groups have come out against the name change, citing the potential for confusion. For now, the AAPA continues to recommend that PAs continued to use “physician assistant” (or PA) as their official title in a professional capacity.
Dr. Setzen acknowledged that some otolaryngologists are reluctant to pursue the PA option, but added, “I suspect that the resistance comes from lack of exposure to working with PAs and hesitancy to commit the time and resources to properly educating and training them, which is a critical component of ensuring good patient outcomes and a successful, collaborative otolaryngology care provision model.” He believes, however, that most otolaryngologists view collaboration with PAs as positive.
Williams’ experience characterizes that mutually rewarding PA–physician partnership. “I work for an exceptional group of surgeons,” she said. “Our relationship is full of trust and good communication that’s built on a strong foundation of training and a willingness to come together as a team.”
Linda Kossoff is a freelance medical writer based in Woodland Hills, Calif.