AAOS Now

Published 6/1/2007
|
Carolyn Rogers

Physician assistants: Scope of practice

What exactly can PAs do? And who decides?

The boundaries of a PA’s scope of practice are defined by the following four factors:

  • State law
  • Education and experience
  • Facility policy
  • Physician delegation

State law
Since the inception of the profession, dramatic changes have occurred in the way states deal with PA practice. The first state laws for PAs, passed in the 1970s, allowed broad delegatory authority by the supervising physician. In some states, these laws were replaced by a more regulatory approach that included detailed checklists of procedures that could be included in a PA’s scope of practice.

By 1996, however—with PAs functioning in a variety of practice settings and a wide range of specialties—the North Dakota Board of Medical Examiners changed the state’s rules governing PAs to adopt a physician-delegated scope of practice. Other states soon followed.

In recent years, much progress has been made in standardizing the regulation of PAs. All 50 states, the District of Columbia, and most U.S. territories have enacted statutes and regulations that define PAs and their qualifications, describe their scope of practice, discuss supervision, designate the agency that will administer the law, set application and renewal criteria, and establish disciplinary measures for specified violations of the law.

State laws now grant physicians broad delegatory authority, which allows for flexible, customized team care.

For summaries of PA laws and regulations for all 50 states, visit the American Academy of Physician Assistants’ Web site at http://www.aapa.org/states.

Education and experience
PA scope of practice should be limited to tasks for which they are adequately prepared.

This preparation is achieved through education and training in an accredited PA program, working with physicians in clinical practice, and through continuing medical education (CME).

PA education is modeled on physician education, and PA students are taught in programs located at medical schools and teaching hospitals. Medical students commonly share classes, facilities, and clinical rotations with PA students.

Prerequisites for admission to PA programs generally include 2 years of college course work in basic science and behavioral science, plus patient care experience. The typical student entering a PA program has a bachelor’s degree and more than 4 years of healthcare experience.

The average PA program lasts 26 months and consists of an intensive classroom and laboratory study phase, followed by clinical rotations in medical and surgical specialties. PA students complete approximately 2,000 hours of supervised clinical practice prior to graduation.

In addition to skills learned in physician assistant programs, PA scope of practice is determined by the base of knowledge and clinical skills gained through working with physicians in the patient care environment, as well as in formal CME courses.

Facility policy
Licensed healthcare facilities have a role in determining the scope of practice for healthcare professionals who practice in their institutions. PAs are typically credentialed by the medical staff and authorized privileges in a manner similar to that used for physicians. Privileges are generally granted in accordance with community need and norms. Any privileges granted by a facility must conform to state law.

Physician delegation
PA scope of practice is determined, in large part, by the delegatory decisions made by the supervising physician. The physician has the ability to observe the PA’s competency and performance and to ensure that the PA is performing tasks and procedures in the manner preferred by the supervising physician. The physician also is in the best position to assess the severity of patient problems seen in a particular setting.

The AMA recognized these concepts when its 1995 House of Delegates adopted the following Guidelines for Physician/Physician Assistant Practice:

  • The physician is responsible for managing the health care of patients in all practice settings.
  • Healthcare services delivered by physicians and physician assistants must be within the scope of each practitioner’s authorized practice as defined by state law.
  • The physician is ultimately responsible for coordinating and managing the care of patients and, with the appropriate input of the PA, ensuring the quality of health care provided to patients.
  • The physician is responsible for the supervision of the PA in all settings.
  • The role of the PA(s) in the delivery of care should be defined through mutually agreed upon guidelines that are developed by the physician and the PA and based on the physician’s delegatory style.
  • The physician must be available for consultation with the PA at all times either in person or through telecommunication systems or other means.
  • The extent of the involvement by the PA in the assessment and implementation of treatment will depend on the complexity and acuity of the patient’s condition and the training and experience and preparation of the PA as adjudged by the physician.
  • Patients should be made clearly aware at all times whether they are being cared for by aphysician or a PA.
  • The physician and PA together should review all delegated patient services on a regular basis, as well as the mutually agreed upon guidelines for practice.
  • The physician is responsible for clarifying and familiarizing the PA with his or her supervising methods and style of delegating patient care.