How to Incorporate a Physician Assistant Into Your Rheumatology Practice

Experienced rheumatology PAs can be a valuable part of the patient care team in busy practices.

The challenges of increasing access to rheumatology care, managing chronic rheumatic diseases, and improving practice efficiency are daunting. In 2007, the Rheumatology Workforce Study highlighted the existing critical shortage of rheumatologists, and the anticipated dramatic shortages by 2025.¹

Physician assistants (PAs) have historically augmented the healthcare workforce for family medicine, but in recent years PAs have become part of many surgical and medical subspecialty teams.² There are only a few one-year postgraduate rheumatology PA fellowships offered in the U.S. The vast majority of rheumatology PAs gain their experience with on-the-job rheumatology training. Currently, 9% of the ARHP membership consists of PAs, but this likely only represents a subset of rheumatology PAs working in clinical practice.

Selecting a PA and developing goals for incorporating one into a rheumatology practice are important decisions. Most PA candidates have prior clinical experience; however, not all PA experiences lend themselves to the practice of rheumatology. Experience in primary care with the management of chronic disease appears to be an optimal background for transition to rheumatology. The use of a PA in a rheumatology practice should be tailored to their primary care strengths in noninflammatory musculoskeletal disease, performing procedures, managing stable rheumatic diseases, and routine new patient consultations.^3,4

The clinical environment for a PA’s on-the-job training varies greatly between academic and private practice. Regardless of the setting, there is a significant learning curve for PAs that can only be reduced with a dedicated commitment to teaching with supervision, especially in the first six months of practice. An academic rheumatology practice with residents and fellows is a natural learning environment to integrate PAs into clinic since the same learning objectives and goals are emphasized for the PAs, residents, and fellows.

In the early months of training, it is imperative to emphasize learning and documenting the rheumatologic review of systems, musculoskeletal examination, assessment of disease activity, diagnosis, and disease management. An electronic medical record with a template note is a useful learning tool for all aspects of documentation. Ongoing supplemental reading is essential for appropriate recommended topics and will enrich the PA’s depth of knowledge of rheumatic diseases, disease-modifying antirheumatic drugs, and biologic therapies.

In a practical sense, a PA new to rheumatology will work in close collaboration with an assigned rheumatologist. The initial PA clinic schedule should be lighter than that of a full-time provider to facilitate time for mentoring. Screening initial patient consultations for new PAs and integrating continuity patients into a PA’s schedule can manage both the workload and complexity of patients seen by the PA. This enables quality supervision for new patients, provides an opportunity to teach about chronic disease and management, and is an effective strategy for on-the-job training. As PAs gain experience and improve their efficiency each month, their clinic appointment schedule can progressively approach that of a fully trained PA or rheumatologist. Once our PA colleagues are fully integrated into practice, they can be very effective providers, team oriented, and loyal to the rheumatology mission and our patients.

PAs can be an invaluable asset to the rheumatology healthcare team. With optimal training and the appropriate rheumatology patient mix, PAs can provide timely rheumatology care and effective outcomes, while enhancing patient safety and satisfaction. Recruiting and training PAs for the rheumatology workforce will allow wonderful opportunities in subspecialty practice and increase patients’ access to rheumatology care.

Dr. Battafarano is chair of the rheumatology service of San Antonio Military Medical Center, adjunct professor of medicine at the University of Texas Health Science Center in San Antonio, and a member of the ARHP Practice Committee.

References

1. Deal CL, Hooker R, Harrington T, et al. The United States rheumatology workforce: Supply and demand, 2005-2025. Arthritis Rheum. 2007;56:722-729.
2. Hooker RS. The extension of rheumatology services with physician assistants and nurse practitioners. Best Pract Res Clin Rheumatol. 2008;22:523-533.
3. Hooker RS. Role delineation of rheumatology physician assistants. J Clin Rheumatol. 2008;14:202-205.
4. Woodmansee DJ, Hooker RS. Physician assistants working in the department of Veterans Affairs. JAAPA. 2010;23:41-44.

Resources for Your Practice

The ACR/ARHP website—www.rheumatology.org—includes an online course for physician assistants (PAs) and nurse practitioners (NPs) called the Advanced Rheumatology Course, which is located in the “Education and Careers” section of the website. This course consists of 19 modules ranging from basic science to common rheumatic diseases. “Module Five: Documentation, Coding and Practice Issues,” covers scope of practice, reimbursement for NP/PAs, and strategies to facilitate successful practice relationships.

Another ACR opportunity for PA training is Rheum2Learn, located in the “Workforce and Training” section of the website. This curriculum was designed for internal medicine program directors and residents to use during a rheumatology rotation. The topics are outlined to match the six core competencies required by the Accreditation Council for Graduate Medical Education. Be sure to read the July issue for more on Rheum2Learn.