Interview with Jeff G. Nicholson, M.Ed., PA-C,

Director of the University of Wisconsin-Madison Physician Assistance Program and President of the Wisconsin Academy of Physician Assistants

By Anna Skrzypek

February 8, 2005 3:30 PM

Q. How would you define the role of a Physician Assistant (PA)?

A. “You can find excellent definitions on the American Academy of Physician Assistants website, www.aapa.org, or on the Wisconsin Academy of Physician Assistants website, www.wapa.org. I will try to paraphrase them the best I can. A Physician Assistant is a nationally-certified and state-licensed healthcare provider who can perform most of the duties of a primary care physician; including specialties of other physicians as well, under the general direction or supervision of a physician.”

Education

Q. What are some majors that can apply for PA school?

A. “First, the major of Pre-Physician Assistance is no longer offered. You can take any major at all. A person can major in anything as long as they fulfill our prerequisite courses. Those 54 prerequisite credits or prerequisite courses are listed on our website, www.physicianassistant.wisc.edu. We welcome any major at all as long as those prerequisites are filled.”

Q. What classes benefit a prospective PA student most?

A. “We are looking actually for well-rounded applicants. We are not looking for a strictly science-based education. However, nationally and at UW-Madison, the majority of applicants are biology majors; but, by no means does a biology major increase or decrease an applicant’s chances of getting into a PA program.”

Q. What do you look for in the volunteer/work experience requirement?

A. “We require healthcare experience in order to get into our program. We do not set a specific number of hours on healthcare experience. However, I will tell you that the average successful applicant has a significant amount of direct patient contact experience and other healthcare related experience, equaling up to even two year’s worth of experience. Many of our applicants are Certified Nursing Assistants, EMTs, or medical assistants. These are three ways in which a student can actually be employed and make money while getting their prerequisite healthcare experience. We are happy to have students apply with non-paid volunteer healthcare experience. The hospitals in Madison have excellent volunteer programs for students. Students may also volunteer at nursing homes. Other very popular healthcare experience specialties include phlebotomists, pharmacy assistants or technicians, and physical therapy assistants. A lot of our more seasoned applicants have been employed in a healthcare field before they have decided to become PA’s. We frequently have a number of applicants who have been EMT's, paramedics, laboratory technicians, radiology technicians; you name it. They come from different allied health employment settings and have significant employment experience before applying to the program. Students may also put down things like being a ski patrol or even a lifeguard as health care-related experience. We do differentiate between direct patient contact experience and healthcare related experience. The direct patient contact experience is much more important and looked upon much more favorably.”

Q. What qualities do you believe benefit a prospective PA student most?

A. “We are looking for maturity and life experience; somebody with good judgment. As a PA, you are going to be making life and death decisions so it is important that you respond rather than react. A very good understanding of the role of a PA and the healthcare system is also very important; another reason why we require direct patient-contact experience. You have to be exposed to healthcare in general to know that it is right for you, and you need to be exposed to PA’s to know that they are not the physician, not the nurse. An understanding of how PA’s fit into the teamwork model of healthcare. Healthcare is really a group effort these days. Physician Assistants are really at the center of that group effort; the team approach to medical care. We strongly recommend that students shadow PA’s as part of their experience and document that in their application.”

Q. What is the reasoning behind the clinical rotations in different socioeconomic areas?

A.  “Our program was originally founded by the Wisconsin State Legislature in the early 1970’s to meet the healthcare needs of Wisconsin’s citizens, especially in medically underserved areas. We still carry that mission with us today. Therefore we really want our students to get exposed to these medically underserved areas so they will in turn, potentially accept a job in those areas. We require our students to do at least one two-month clinical preceptorship in either a rural medically underserved area or an inner city medically underserved area of the student’s choice. It really is a complementary package of exposure to all the different employment opportunities for PA’s.”

Employment

Q. Where do you feel PA’s are most-needed?

A.  “Physician Assistants are definitely most-needed in medically underserved areas and in primary care. There is a huge shortage of primary care physicians and clinicians in this country. There are over forty-million uninsured Americans right now and I see the role of the PA to help meet that need; to solve the nation’s healthcare crisis in terms of giving access to high-quality, cost-effective healthcare to the uninsured and underinsured.”

Q. What types of settings and specialties are offered for PA’s?

A. “PA’s can work in any medical specialty. The only requirement by Wisconsin regulations right now is that the PA may not practice in a specialty outside of the scope of practice of their supervising physician. The reasoning for this is that the PA must be able to turn to their supervising physician for questions and counseling within the expertise of that field.”

Q. What would an average work week for a PA be like?

A. “This varies tremendously depending on the PA’s specialty. An example of a primary care PA may be one of two possible types.  One typical scenario would be a PA working a basic eight hour day for a HMO, seeing patients in the clinic. This would consist of seeing a patient every twenty minutes for a routine healthcare need. Usually, routine physical exams are scheduled for thirty minutes, while other issues are scheduled for fifteen to twenty minutes. The other scenario would be a PA in a small town clinic who may be in the clinic, but also do rounds in a local hospital. This PA may also go to the emergency room if one of their patients or their supervising physician’s patients would need to be assessed for an admission. This PA may also do house calls, nursing home rounds, or even be the medical director for a community volunteer ambulance crew. A surgery PA on the other hand, may have early morning surgeries scheduled, and in the afternoon they would be in the clinic and see follow-ups from prior surgeries. Lastly, before leaving for the day, the PA may do rounds of the patients in the hospital. A PA’s week can range from 40 to 70 hours depending on specialty and work setting.”

Q. What are the exact policies for PA’s to prescribe medication?

A. “Physician Assistants may prescribe all medications right now, including controlled substances (narcotics), as long as the PA has a Drug Enforcement Agency (DEA) number. PA’s must apply for the number and pay a registration fee every three years to renew it. The specific regulation that PA’s have in order to prescribe, is that any patient charts or records that they have written a prescription order for must be countersigned by the supervising physician within seventy-two hours. Currently, the Wisconsin Academy of Physician Assistants is working with the Wisconsin Medical Society, which represents physicians, to change the practice regulations for PA’s. They are hoping to eliminate the chart countersignature requirement.”

Q. What is the difference between a Nurse Practitioner and a PA?

A. “In a nutshell, the two are very different philosophies and two different models of training. Nurse Practitioners are first and foremost nurses. They have to go through nursing training, they have to learn nursing care models and they emphasize bedside care. Physician Assistants on the other hand, follow the medical model of training with an emphasis on diagnosis and treatment. They follow a medical school curriculum, take courses alongside medical students, and are taught by the medical school faculty. The PA profession provides greater flexibility in that they are trained as generalists to provide primary care services and other services in any medical specialty. Nurse Practitioners take Nurse Practitioner training in specific programs to practice in a certain specialty (such as pediatrics, women’s health, or critical care); it is more focused. Physician Assistants also receive a higher amount of clinical training in their programs; over two-thousand hours of clinical training on average, whereas Nurse Practitioners clinical training ranges from 500-700 hours. Another difference is that Nurse Practitioner programs tend to be more flexible and part time.  They tend to combine didactic (book learning) and clinical training while students continue to work as nurses.  They may also earn one type of many possible certifications from varying curriculums and certifying bodies. Physician Assistant programs are largely fulltime and there is only one national certifying body with a consistent curriculum.” 

Q. What are the continuing education and examination requirements for PA’s?

A. “Physician Assistants must take a National Board Exam after graduating from an accredited PA program. The exam is six hours long with three-hundred fifty questions. After passing the examination, PA’s must recertify every two years by completing one-hundred hours of continuing medical education credits. Half of the credits must be ‘Category One’ credits, meaning that they are lecture-type credits or conferences. ‘Category Two’ credits include precepting other PA students or lecturing in health programs. In addition, every six years PA’s must take another National Certifying exam similar to the first one taken upon graduation. It is a very stringent recertification process to assure the public and other health disciplines that PA’s are providing high quality care.”

Q. What are the malpractice insurance requirements of PA’s?

A. “PA’s are generally covered under their supervising physician’s malpractice policy or the policy of the hospital or clinic they are employed by. PA’s are encouraged to carry additional separate malpractice insurance, but they are not required to and very few do. It is actually very inexpensive for a physician to add a PA to their policy; approximately one-thousand dollars per year.”

Q. Do you have any interesting or unique experiences that you have come across in the PA profession?

A. “After graduating, I practiced family medicine in a small town in North Dakota.  Another PA and I were pretty much the only healthcare providers for the entire county. It was a very difficult job for a brand new graduate, and I learned tremendously in the two years that I worked there. I loved the town and I loved the people that I served. People in the grocery store would talk to me and ask me about their health problems. People would bring me chickens for treating family members. The local mechanic would let me use his garage any time I needed to and things like that. One farmer brought me a tractor tire to use as a sandbox for my newborn child.  It was a very close and caring community. I was also the medical director for the volunteer ambulance crew. I led a charitable campaign for United Way one year as well. The people really embraced me as a major contributor to the community. One thing I did not like about that job was being “on call”. I had to carry a pager and be on call every other night and every other weekend. When that pager went off after hours, it could have been two in the morning and I wouldn’t know if it was just a child with a fever or if it was someone having a heart attack. It was very stressful to worry about how serious the medical condition was going to be on the other side. It was also stressful knowing that you would have to do advanced cardiac life support (ACLS) and start IV’s on people in serious conditions. One time, I was called out to the interstate bypass because some high school student had gotten into a major car wreck. There were actually three very seriously injured high school students  -  we had to call in helicopters to take them to the hospital. Those were the parts that I did not enjoy.”

Q. How would you describe Physician-Physician Assistant relationships?

A. “My experience has been that ninety-eight percent of the time they are excellent. Most of the doctors I have worked with in Emergency Medicine are extremely supportive, respectful and appreciative because the whole theory is that PA’s are there to help them and ease their patient load. Once physicians understand that PA’s are not there to compete or threaten their livlihoods, but that PA’s are there to help them, then physicians work with PA’s very well. The atmosphere is very collegial. There are the occasional few who just do not like PA’s or Nurse Practitioners. However, most physicians largely welcome PA’s and work very well with them.”

Q. What do PA’s offer that Physicians cannot?

A. “Patients are largely impressed by the profession once they understand it. PA’s tend to be able to spend more time with the patients or at least patients perceive that they do.  PA’s are also able to explain medical terminology to the patients in terms that the patients can understand. PA’s have less of the liability concerns and the pressure for productivity than physicians. As a result, patient satisfaction with PA’s is extremely high. The studies that have been done show that patient satisfaction with PA’s is equal to or even higher than patient satisfaction with physicians. Patients feel that PA’s really care and are less rushed than physicians.”