How to use (and how not to use) urology PAs

Physician assistants are rapidly increasing in number, making their presence in all fields of medicine more common. With an estimated 101,977 licensed PAs reported by the 2014 National Commission on Certification of Physician Assistants census, PAs have grown by 36.4% in the past 5 years. Of those, 1.4 % were practicing in urology at the time of the survey.

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However, the need for urology providers is expected to increase considering the aging population of practicing urologists. According to the AUA 2014 census, nearly 23% of practicing urologists are 65 years of age or older. As they retire, PAs will be called upon to help fill the provider deficit.

An additional strain on academic medical centers is resident work hour restrictions. Academic medical centers will often integrate PAs to help offset these limitations and to augment the learning opportunities for the residents. PAs are commonly responsible for both inpatient and outpatient care. As outpatient providers, we can evaluate both new and returning patients, order and interpret laboratory data and diagnostic imaging, provide patient education, and perform outpatient procedures such as cystoscopy, transrectal ultrasound prostate biopsy, and insertion of testosterone pellets (Testopel).

Next: "Some institutions are now utilizing PAs as dedicated first assists on robotic procedures."

As inpatient providers, we can see emergency department and inpatient consultations, perform preoperative and postoperative rounds, admit or discharge patients, and perform procedures such as difficult Foley placement, priapism irrigation, abscess incision and drainage, and bladder irrigation. Intraoperatively, we can first assist on open, laparoscopic, or robotic procedures. Some institutions are now utilizing PAs as dedicated first assists on robotic procedures.

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I began my career as a PA working in an internal medicine subspecialty, but always knew I would find my way into urology eventually. A year and a half later, I accepted my first urology position. I could not have been more excited to start my dream career.

That excitement rapidly turned to frustration as I quickly realized I had joined a practice that did not know how to integrate a PA appropriately. I pleaded with my supervising physicians to institute a structured orientation to ensure I was properly trained prior to seeing a full clinic schedule and performing inpatient rounds independently. There was significant confusion about my role in the practice. Some physicians viewed me as a perpetual intern who would carry out all the mundane tasks with absolutely no hope for career advancement or professional growth and development. Others thought my role was to see all walk-in patients and spend the remainder of my time assisting with nurse visits and answering phone calls.

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In addition, no one could agree on the appropriateness of a PA performing procedures in the office or inpatient setting. Unsurprisingly, there was significant contention among the physicians and myself regarding my role in the practice.

Next: "My second urology position was remarkably different from the first in every way."

My second urology position was remarkably different from the first in every way. I was welcomed into a large academic practice with PAs who were well established. The mentorship program of experienced PAs and physicians ensured that I was adequately trained. Clear clinical, surgical, and educational goals were in place and clearly outlined. Regular evaluations ensured that I was progressing. Autonomy gradually increased as I progressively met my educational goals.

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The role of the PAs in the practice was fluid and adaptable. Over the years, the PAs accepted more responsibilities and learned new skills. They were encouraged to pursue patient subsets that interested them. Finally, all my urology dreams had come true. Within a year, I was independently performing outpatient procedures, first assisting in robotic surgeries, and managing inpatient and outpatient duties with confidence.

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My first urology experience left me wondering what the role of a PA in urology should be. Five years later, I still frequently contemplate this question. Perhaps some of the confusion surrounding the role of a urology PA stems from lack of prior experience and understanding of the possible ways PAs can be integrated into a urologist’s practice.

Next: Using the AUA Consensus Statement on Advanced Practice Providers

Thankfully, we can now refer to the AUA Consensus Statement on Advanced Practice Providers for guidance. The consensus statement outlines how PAs (and other advanced practice providers) are educated and proposes a mentorship program with varying levels of physician supervision and defined skill levels to which to aspire. The goal is to cultivate a PA who can adeptly manage complex patients and formulate appropriate treatment plans with remote physician supervision.

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The consensus statement also provides information on key issues such as physician-PA supervision regulations, Medicare/Medicaid regulations, and integration of PAs into practice. I truly hope all practicing urologists become familiar with the consensus statement and refer to it prior to adding a PA to their practice. Just as importantly, PAs need to utilize the guidelines in the consensus statement when discussing their practice goals with their supervising physicians.

Ultimately, the role of the urology PA should be to meet the needs of their practice and patient population while fulfilling their own career goals. Urology PAs should become familiar with current literature, such as the AUA Consensus Statement on Advanced Practice Providers, to advocate for themselves and achieve their desired role. A continuing open discussion with their supervising physicians is essential to ensure the PA-MD relationship is maintained and evolving in a way that makes sense.

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