Certified PAs Expanding Roles in Rural Hospital Settings
According to the Congressional Budget Office report, demand for primary care will increase 18 percent between now and 2023. This demand is hitting at the same time there is a growing shortage of primary care physicians, especially in rural markets. For instance, the National Rural Health Association reports that patient-to-primary-care-physician ratios in rural areas is only 39.8 physicians per 100,000 people, compared to 53.5 physicians to 100,000 in urban areas. The Association of American Medical Colleges reports that while 20 percent of the U.S. population resides in rural areas, only 10 percent of physicians practice in those markets.
Certified physician assistants (PAs) are stepping up to deliver high quality care in every specialty and clinical setting. We are certified at the highest levels of healthcare, maintaining certification by earning 100 hours of CME every two years and then completing a rigorous assessment in core medical knowledge every 10 years. As providers, we perform many of the same services and procedures as physicians, making us cost-effective additions to medical teams.
Some rural hospitals cannot afford to maintain a physician staff that may only see 6-12 patients per day or have only a few patients daily in the emergency department. This is where Certified PAs can help rural hospitals reduce staffing costs, assuring that they stay open and remain economically viable.
According to NCCPA’s 2016 Statistical Report of Certified Physician Assistants, 2.2% or over 2,500 PAs work in rural health clinics. That is in addition to the almost 40% of PAs who work in hospitals throughout the U.S., including rural areas.
The report shows that states like Alaska, Idaho, Montana, and Nebraska, have some of the highest percentages of PAs per capita. Many of these PAs provide the most needed services for those areas. The statistics show that about 38 percent of all PAs serve in primary care, pediatrics, internal medicine and related specialties (cardiology, oncology, gastroenterology), with another 33 percent in other high demand areas such as emergency and hospital medicine and obstetrics/gynecology.
Edward Amberg, PA-C, and Kristy Thomas, PA-C, put faces to these statistics. Amberg works at St. James Healthcare in Butte, Montana – a hospital so remote that the nearest Level 1 trauma center is two states away, either in Salt Lake City, Utah, or Seattle, Washington. He assumes multiple roles practicing in an outpatient clinic, emergency department, hospice and hospital. This fluidity is typical in PAs, who are trained in general medicine and can offer care in multiple areas of medicine. They also often bring prior healthcare experience as paramedics, nurses, lab techs, or other healthcare-related professions due to admission requirements of many of the nation’s PA programs.Thomas meets patient needs at a small clinic situated in a rural New Mexico town of about 1,600 inhabitants. The clinic is the most remote of the network’s 11 locations – about 40 minutes away from the next nearest clinic. It is an outpatient setting that utilizes resources from hospitals to coordinate ambulance services or summon life-flight helicopters for medical emergencies.
Most of her patients are Hispanic so she must communicate in Spanish for about 90 percent of her cases. Since the clinic sits just north of the Mexican border, some patients are undocumented, and many are uninsured and at or below poverty-level. For them, she is their sole option because they are trapped between the border and the border patrol check point further north.
Rural health PAs face limitations like their patients. Often, they must phone or use telehealth methods to reach other health care professionals which creates a sense of professional isolation. In Thomas’ case, about 50 miles separates her from her collaborating physician, so she reaches him by phone. There’s an added layer of complexity because she’s in a community where patients may be apprehensive about visiting a clinic due to their immigration status or have limited understanding of the English language.
PAs must consider educational limitations and cultural and social differences in these small communities. It’s a tough sell because healthcare providers are often drawn to practice in suburban and urban areas, which can offer higher salaries, access to more sophisticated technology and opportunities to specialize in an area of medicine. For instance, Thomas’ clinic doesn’t have a CT scanner, so she heavily relies on her physical examination skills to diagnose and treat her patients. In addition to challenges attracting talent, rural hospitals are also competing against efforts to secure support in state legislatures, where reduced attention towards rural communities can proliferate health disparities and unequal access to care.
However, rural hospitals offer rewards to those who choose to work in these settings. At National Health Service Corps-approved sites, PAs can receive tax-free loan repayment assistance for working in an underserved area. Since PAs can comprise a large portion of medical staff in rural hospitals, employers can promote that they are involved in the direction and policy making for the facility. Rural settings can also give them the independence to handle a full spectrum of cases, often outside the immediate reach of a physician.
Overall, PAs in rural medicine find rich rewards in treating patients who may have compromised, or neglected, their health just because of where they reside or limited resources. Equal access to quality care is a right, and PAs have a long history of extending that right to patients in rural areas.
According to a recently published NRHA policy brief, physician assistants have the potential to help combat the shortage of physicians in rural communities and improve access to health care.
Dawn Morton-Rias, Ed.D, PA-C is president and CEO of the NCCPA, the only certifying organization for physician assistants in the United States. The PA-C credential is awarded by NCCPA to PAs who fulfill certification, certification maintenance and recertification requirements. NCCPA also administers the Certificate of Added Qualifications (CAQ) program for experienced, Certified PAs practicing in seven specialties. For more information, visit www.PAsDoThat.net.
Photos by Eddie Amberg, PA-C.