In the ongoing conversation about physician assistant/associate (PA) practice, there is a theme of understanding when an individual provider can see specific patient populations and various complexities.
Determining when PAs can be expected to make diagnoses and treat a patient population based on their education and experience is key to granting a scope of practice. Important in this process is ensuring that the clinician has the insight to recognize their limitations and the need to collaborate with others. It is all about trust that a PA can perform at the level of practice that has been granted.
Graduated autonomy has been a successful paradigm for PA practice since our profession was created. This means that a PA’s scope of practice was decided at the practice level and increased over time based on their education and experience. The original supervisory model assumed that a PA would be practicing with a physician who would oversee experiential learning and delegate expanded scope of practice according to their judgment.
Medical practice and the business of medicine have changed over time, which has presented barriers to the supervisory model. Considering the details of these factors is important as we work to find practice models that keep up with the needs of patients in our healthcare system.
Current medical practice faces the challenges of creating a space where health equity is available for all patients in the context of rapid change and advancement of medical science. There is a need to both expand primary care services while ensuring that healthcare professionals can explore the frontiers of new medical science in all medical specialties.
The business of medicine has long been trending toward corporatization of the healthcare systems to streamline care and introduce efficiencies. There are benefits and drawbacks to this reality, and all stakeholders need to understand both.
The reality of current medical practice and the business in which it resides makes the supervisory model of PA practice problematic. The original concept of one PA and one physician having the luxury of creating a practice relationship together is increasingly rare. We need to consider other models for the benefit of our patients.
The collaboration model has been introduced as an answer to these challenges. The collaboration model continues to assume that scope of practice is decided at the practice level. It also assumes that physicians are intrinsically involved in the process of granting scopes of practice as PAs enter the workforce.
The difference is that graduated autonomy opens the PA to practice in collaboration with the entire healthcare team and not only with one physician. The healthcare system grants specific autonomy based on practice-level judgement, which is then decided by committees who oversee the granting of privileges as well as the oversight of clinicians in their system.
The key for this to continue to work for the benefit of patient health and safety is that there is a community of healthcare system leaders who are engaged with deciding what level of autonomy a PA has and execute an effective quality assurance process that can find and address issues when they arise.
The challenge of the collaboration model is how to best determine the scope of practice for an individual PA. Health professions educators may be developing a paradigm we should consider.
Competency-based medical education has been embraced by both undergraduate medical education as well as PA education. Being explored is the concept of entrustable professional activities (EPAs) as assessments of competency based education.
An EPA is an observable unit of work that is evaluated by individuals who have the authority to grant entrustment. This results in the unit of work being trusted to the individual by a committee. This is a way to evaluate an individual and decide when they are ready for the activity in their practice.
While EPAs are being considered in many areas of health professions education, their validity and reliability need to be better understood. This idea is not ready to be introduced into practice on a large scale. However, there are opportunities to create pilot projects to better understand the paradigm and see how it might be appropriate.
I can see a future in which PAs enter practice with certain EPAs required; the individual is evaluated on these activities; and the scope of practice is determined by a committee at the practice level. This can be re-evaluated over time to either increase the level of autonomy or add new practice responsibilities.
There might be a variety of evaluators to reflect the diversity of our healthcare system. Board-certified physicians, PAs, nurses, and other members of the healthcare team could sit on the committee to reflect practice needs.
A PA could carry a portfolio of granted EPAs and their levels of autonomy to allow portability of their accomplishments. This could then be confirmed at their next practice through another assessment to ensure that their knowledge and skills are current.
Patients need the healthcare community to innovate so that all members of the team can contribute in a way that provides the best quality and safest care for all. Understanding what level of graduated autonomy to grant is important so that we have people with the right preparation in the right places.
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About David J. Bunnell, MSHS, PA-C
PA Bunnell’s clinical experience is in cardiac electrophysiology, cardiothoracic surgery, and surgical critical care. Prior to becoming a PA, he was a paramedic, organ recovery coordinator, and research coordinator. He serves in PA leadership and advocacy roles to communicate the profession’s value to patients and healthcare systems as well as to encourage the PA community to continue to do amazing things.