PAs make big strides, but still face hurdles

National Report-Physician assistants (PAs) say their roles in urology have blossomed. But challenges remain. Many urologists, they say, are reluctant to allow PAs to practice their full scope. That resistance, according to PAs, tends to be based on urologists’ lack of understanding about what PAs do and don’t do. And it prevents PAs from accomplishing all they can for urologists and patients.

The glut of new urology patients entering the health care system under the Affordable Care Act has urology practices increasingly relying on PAs and other advanced practice providers to help meet demand. From the viewpoint of several PAs interviewed by Urology Times, their expanding role in a rapidly changing health care landscape requires urologists to take a fresh look at how to make the most of these providers’ skills and abilities.

Mary Mathe, PA-C, is a busy, experienced, and politically active urology PA. Mathe is in part-time clinical practice at Florida Urology Associates, and works full time as a medical science liaison for Pacific Edge Diagnostics USA. She has served as vice president of the Urological Association of Physician Assistants (UAPA) and liaison to the AUA on behalf of UAPA.

Mathe says PAs in urology have made big strides in the last decade.

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“As a clinical PA, my role over time has expanded to a more autonomous position within clinical practice, with oversight as needed by my supervising doctor. Over the years, I have been taught to perform procedures such as cystoscopy and transrectal ultrasound [TRUS] biopsy, which is consistent with the progression of PAs in this country. I went from being a part of my doctor’s clinic to building and running one at one of the largest robotic programs in the country,” Mathe said.

“From a political standpoint, I also went from not being able to join the AUA to the one who assisted in the development of the allied health category. [I became] the first PA appointed as a voting member of the educational council, first chair of the AUA’s APN/PA Education Committee, as well as the first PA to present at plenary at the annual meeting. This progression was not possible 10 years ago.”

Urologists resistant?

Progress aside, urologists remain hesitant to use PAs to their full capacity. One reason, PAs say, is that urologists often don’t understand PAs’ capabilities and roles in urology. Other issues fueling continued resistance include concerns about reimbursement and turf.

Urologists remain reluctant to have PAs perform procedures such as cystoscopy and TRUS biopsy, Mathe says.

“[Physicians] can ‘resist’ all they like and refuse to let their PAs perform certain procedures or see certain patients, but the reality is that a PA can do almost anything their supervising MDs allow them to do,” she said. “Simple surgical procedures can be performed without the MD but major surgeries cannot.”

Urology, as a whole, has been slow to integrate PAs into a team-based practice. That’s while other specialties, including primary care, cardiothoracic surgery, orthopedics, emergency medicine, and dermatology have a more robust integration of PAs into their practices, says Brad Hornberger, MPAS, PA-C, faculty associate and program director of the Physician Assistant Postgraduate Urology Fellowship at UT Southwestern Medical Center, Dallas.

Hornberger refers to the “us-versus-them” mentality that some urologists have against PAs working in urology practices.

Mr. OgunfiditimiUrologists’ resistance to using PAs is a bigger challenge to the expansion of PAs in the specialty than laws governing PAs, according to Folusho Ogunfiditimi, DM, MPH, PA-C, director of mid-level providers, Detroit Medical Center, Harper University Hospital.

“From a regulatory-legislative standpoint, PA practice across the nation has grown by leaps and bounds over the past 10, 20, 30 years. The general scope of practice in most states for PAs is liberal enough to maximize the utilization of those PAs,” Ogunfiditimi said. “However, when it comes down to the individual organizations… they have a hesitancy to open up the scope of practice of PAs for a multitude of reasons.”

However, the resistance to PAs in urology might be eroding thanks in part to the AUA’s support of PA education, according to Mathe.

“More and more courses are being provided at both the AUA annual meetings and AUA-sponsored stand-alone courses, AUA sectional, state, and local meetings… not only for the education of PAs but also for the education of physicians on PAs,” Mathe said. “Continuing to offer courses to both PAs and physicians on proper coding of a PA’s work will also alleviate some of the concerns over money and reimbursement.”

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Not all PAs think they’re being underutilized or held back in the specialty. Kevin Wayne, PA-C, senior physician assistant at the University of Southern California Institute of Urology in Los Angeles, says his job is predominantly to support urologists in the group by sharing in patient care at the clinic level. He also participates in research projects and co-directs a 1-year PA residency in urology.

Mr. Wayne“Currently, I don’t see many challenges or problems as a urology PA. Initially, back when I started in the specialty, it was difficult to persuade or convince the referring physicians in the community of my expertise in urology. This was hard-earned and was augmented by the support of the urologists I worked with,” Wayne said. “Any resistance would likely result from hiring a PA without urology experience and sculpting them into a skilled urologic practitioner. How do you begin to distill 6-plus years of residency training into sizable bites for a mid-level practitioner?”

Guidelines lacking (but not for long)

There is no set standard by which PAs are trained in urology, other than what they get from supervising physicians. And that varies from physician to physician and practice to practice, says UAPA President Tim Irizarry, MS, NREMT-P, PA-C. But standards for practice are in the works, says Irizarry, who is a PA with Arkansas Urology and its subsidiary Epoch Men’s Health in Little Rock.

“The guidelines are still being formulated for a ‘framework’ that urologists across the nation can use as a standard for their advanced practice providers-PAs and advanced practice registered nurses-in a white paper that should be out later this year,” Irizarry said. “I am fortunate enough to have been asked to be part of this groundbreaking and team-building work.”

Look for the AUA statement on advanced practice providers to receive final approval from the Board of Directors this fall.

Mr. IrizarryThe standard to which PA schools train all PAs is set by the National Commission on Certification of Physician Assistants, a medical model much like that used to train physicians in medical school, Irizarry says. But there is no program to give PAs additional certification in urology, he says.

“As a PA, I can obtain a Certificate of Added Qualifications in many specialties [including pediatrics, hospital medicine, psychiatry, and orthopedics], but currently not in urology. There are postgraduate residencies available in urology, but these are the exception rather than the needed norm,” Irizarry said.

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Educational opportunities for PAs in urology are improving, according to Hornberger.

Mr. Hornberger“The UAPA offers an annual CME conference including didactic lectures, as well as hands-on courses for things like cystoscopy, percutaneous tibial nerve stimulation [PTNS], and ultrasound. The Society of Urologic Nurses and Associates (SUNA) offers an advanced practice track for APNs/PAs, including didactic lectures and hands on courses as well. The AUA has increased their educational opportunities to PAs, but has been less inclined to offer procedural training,” Hornberger said.

Best practices for PA use

In general, PAs are underutilized in urology and could play a bigger role in supporting supervising physicians and caring for patients, according to Irizarry.

Urology is an excellent specialty for PAs because of the way the specialty is structured as a surgical specialty, with a large ambulatory complement, according to Ogunfiditimi. “PAs fit very well in urology because you can use them in all three sectors of health care delivery: in an inpatient setting, outpatient setting, and in the operating room,” Ogunfiditimi said.

PAs, according to Mathe, are ideal providers for developing and running specialty urology clinics, such as those in men’s health and female sexuality. Another setting well suited for PAs, according to Mathe, is the fast-track clinic, where PAs see urgent walk-in patients, which can significantly reduce that burden on the MD.

“Having a PA take first call can decrease the MD’s trips to the hospital or clinic, with proper triaging and writing of consultation notes,” she said.

Robotics is part of the expanding PA-urology practice.

“Our robotic program includes PAs as first assistants to provide experienced first assistant support to deliver excellent intraoperative care, as well as reducing OR time,” Hornberger said. “We have found this assistance to enhance the urology residents’ training experience, which is contrary to conventional wisdom.”

Currently, UT Southwestern has five urology PAs and one PA fellow participating in the postgraduate fellowship program. The urology PAs, according to Hornberger, manage a variety of urologic conditions; perform outpatient procedures, including cystoscopy, difficult catheter insertion, TRUS with prostate biopsy, and PTNS; manage inpatient consults; and first assist on robotic urologic surgeries.

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With all its promise, the role of PAs is not without its limits, PAs agree.

“I, as a physician assistant, am just that: an assistant. I assist the physician in seeing his patients, whether they be an established patient or new,” Irizarry said. “At the end of the day, that patient belongs to the physician. I am not here to ‘steal’ or take away patients from my supervising physicians.”

Where PAs work should be at the discretion of the supervising physician, according to Irizarry.

“In any area of urology where there is the possibility of endangering patient safety or there is high medical-legal risk, performing any such tasks would be considered inadvisable,” he said. “No PA should perform any duties delegated to him or her without the appropriate training necessary to safely perform any tasks involving patient care.”

Recruiting and retaining the best possible PAs in urology will require that urologists allow PAs to practice to the fullest extent of their training and provide opportunities for them to learn and grow as urology providers, according to Hornberger.

Legislative hurdles

PAs continue to fight for legislative wins they say would help not only PAs, but also urologists and patients.

“An area where we tend to struggle as PAs at the federal level, based on CMS regulations and existing legislation, is in being able to appropriately bill for services provided by PAs and NPs,” Ogunfiditimi said. “Medicare pays between 80% and 85% of the work done by a PA or NP, but pays 100% to an MD even if the work and outcomes are the same. This can be a deterrent to… urology practices in terms of the utilization of PAs.”

Mathe says legislation in Florida that prohibits her from prescribing controlled substances is a significant burden.

“I see patients with low testosterone that I treat on a regular basis, as well as patients with kidney stones. I cannot prescribe testosterone for a patient or pain meds,” Mathe said. “This, overall, slows down clinic flow, with the need to go to a supervising MD to write this. Since we do not have to have our supervising physician on site in order to practice, this creates a significant burden on the clinic and, more importantly, the patient who must wait or return to pick up the prescription.”

Mathe says there are issues facing the American Academy of Physician Assistants, the national association promoting PA practice. Electronic health record incentives for PAs is one.

“If an MD, dentist, or advanced practice nurse has 30% or greater indigent population, they receive incentives for this,” Mathe said. “PAs were left off of this list.”

Allowing PAs to provide hospice care and order home health services are other burning issues.

“Although a PA may see Medicare patients for all their care, Medicare will not reimburse a PA who continues or starts care on a hospice patient,” Mathe said. “Medicare requires an MD’s signature on all HHS orders. This is particularly difficult in rural and urban medically underserved areas, where PAs may be the only health care professionals on site, or in clinics staffed by PAs who provide night and weekend care.”

PAs and urologists are at an important juncture in health care, Irizarry says.

“We can either expand our vision and embrace the fast-changing future with the onslaught of new patients with whom we are about to be faced,” Irizarry said, “or continue with our current status quo and be overworked, miss payment opportunities in the changing health care marketplace, and see our field fall far behind in both patient satisfaction and quality of patient care.”UT

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Potential benefits of a urology practice-PA partnership

Brad Hornberger, MPAS, PA-C, faculty associate and program director of the Physician Assistant Postgraduate Urology Fellowship at UT Southwestern Medical Center, Dallas, says urology practices could realize many benefits by using PAs to their full scope of practice, including:

• increased appointment availability and more timely access for patients including urgent and same-day appointments

• increased work flow efficiency and coordination of care by PAs (PAs can do initial workups on patients, screening them for surgical conditions to be referred to the most appropriate urologist in the group while managing many of the non-surgical cases. This frees up the surgeon to see patients who need surgery.)

• care of patients in a men’s health clinic

• medical management of recurrent kidney stone disease

• care of patients in a bone health clinic (for patients on androgen deprivation therapy)

• care coordination for post-prostatectomy patients regarding incontinence and sexual function rehabilitation

• first assisting in the operating room, freeing the urologist partner to see new patients in the outpatient clinic setting

• management of inpatient consults and postoperative patients

• performance of procedures, including cystoscopy, cystoscopy with stent removal, testosterone pellet (Testopel) insertions, intracavernosal injections, transrectal ultrasound with and without prostate biopsy, gold fiducial marker placement for intensity-modulated radiation therapy, and difficult catheter placement

• participation in clinical trial research activities

• follow-up care and cancer survivorship programs for urologic oncology patients.

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In March 2011, the American Academy of Physician Assistants identified these elements of state law (which vary from state to state) as the “Six Key Elements of a Modern Physician Assistant Practice Act. These include:

• “licensure” as the regulatory term (instead of “certification” or “registration”)

• scope of practice determined at practice site

• adaptable supervision requirements

• full prescriptive authority

• chart co-signature requirements determined at the practice

• number of PAs a physician can supervise determined at practice level.

For more detailed information on each of these six elements, visit www.aapa.org/workarea/downloadasset.aspx?id=628.

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