The expanding role of certified physician assistants in cardiac specialties

by Joseph A. Dearani, MD; and Michael J. Nowak, PA-C, FAASPA

Demand is high and supply is low. That is the simple economics behind one of the many critical challenges facing the cardiology profession today. It also is one reason for the current growth in physician assistants who specialize in cardiology and cardiac surgery.

With the escalating demand for quality cardiac services, finding better ways to integrate physician assistants (PAs) into care teams is vital. Such efforts can become core components of a strategy to improve outcomes and patient satisfaction.

Joseph A. Dearani

The key to reaching these goals lies in greater communication, understanding the roles and capabilities of PAs, and a commitment to ensuring the development of collaborative teams with aligned goals.

Number of PAs rising

According to current estimates from the National Commission on Certification of Physician Assistants (NCCPA), nearly 2,500 certified PAs work in cardiology, and another 3,000 certified PAs work in cardiac and thoracic surgery. That number is expected to rise as the number of PA programs will increase by 30% in the next 4 years, growth that may keep pace with an aging population that will need its fair share of PAs to meet the growing need for cardiology care.

Surveys of PAs in cardiology and cardiac surgery have shed light on what they do.

Michael J. Nowak

Results of a 2012 survey by the American College of Cardiology indicated that most cardiology PAs are in a group-practice setting (48%) or a hospital-based practice (33%). Most respondents provided both inpatient and outpatient care (77%). The survey listed 15 procedures and asked PAs to choose those procedures for which they were the primary clinician. The most common procedures performed included:

aortic balloon pump removal (56%);
elective cardioversion (48%);
central line placement (34%); and
Swan-Ganz placement (26%).

A survey of cardiac surgery PAs conducted by the NCCPA in 2010 listed 34 procedures and asked PAs to select which ones they perform and how often. The top procedures performed more than once a day included:

surgical first/second assist;
sternal/thoracotomy closure;
endoscopic saphenous vein harvesting; and
conduit vessel harvesting.

Collaborative environment

An example of what PAs are doing can be found at the Mayo Clinic in Rochester, Minn. There, physicians work closely with PAs and nurse practitioners (NPs) in an environment where everyone is salaried, resulting in a patient-centered environment that eliminates unnecessary procedures.

Our surgeons are familiar with the entire spectrum of heart disease. However, we also focus on specialty areas, such as valve repair, congenital heart disease, robotic and minimally invasive, aortic, HF and transplantation. Expert clinicians specialize in specific procedures and perform many of those operations.

PAs at most institutions work as part of the operating room team with physicians and residents. With restrictions on work hours for residents, PAs and NPs have also stepped in to fill demand and provide vital services, performing the pre-op evaluations and caring for critical patients on a moment to moment basis after surgery.

Like physicians, PAs are encouraged to specialize in a niche area by earning CME and training with a physician in that area. For example, PAs may decide to focus on taking care of pediatric patients with congenital heart disease or adults with HF requiring a ventricular assist device or heart transplant. Our patients can be in the hospital for as little as 2 days, and PAs, NPs, cardiologists and surgeons are all involved in that patient’s care from admission to discharge.

PAs and NPs also handle rounds and update physicians on patient status, key vital signs, medications, comorbidities, family dynamics and other conditions that could have a significant impact on outcomes, patient experience and hospital stay. They are the “diamond in the sky” for this practice, and the key to continuity.

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Education is key

One of the most critical tasks PAs can perform — one immensely valuable to surgeons and cardiologists and patients — is education.

PAs take time before discharge to counsel the patient and caregiver about the need to maintain medication adherence even if the patient “feels good.” The PAs emphasize the positive impact on families of making important lifestyle changes, such as eating a healthy diet, exercising and quitting smoking vs. the negative impact on quality of life that comes from not committing to those changes.

This education gives patients the tools they need to successfully maintain good health once they are at home in their own environment.

Patient satisfaction

PAs also play a key role in improving patient satisfaction, which is a critical step in today’s results-driven climate.

Mayo Clinic’s worldwide draw speaks to its excellent reputation for quality outcomes and patient satisfaction. We often have high-profile and demanding patients with high expectations, and PAs and NPs are very strong with communication and making sure the patient understands what is happening and why.

Also in the case of an unexpected poor outcome, PAs, who have been the face at the bedside most of the time, are an incredible resource and sense of consolation to the family. They can be pivotal to a family leaving the hospital relatively content under untoward circumstances.

All patients fill out a survey when they leave, and almost consistently the feedback includes positive words about the PA and NP staff. There is a recurring theme of gratification from these patients and their families, and we measure and quantify these results.

Addressing concerns

Cardiologists and cardiac surgeons have been working with PAs for more than 5 decades, since the 1970s. Yet, still there remain misperceptions among physicians and patients. To meet the challenges of today’s health care system, these myths and misunderstandings must be directly addressed.

One of the most pervasive of these myths has to do with education. The PA concept was developed by busy physicians working out of Duke University in the 1960s. PAs are educated using the medical model and are licensed through state medical boards. Similar to physicians, PAs maintain certification by completing ongoing CME every 2 years, including CME focused on performance improvement and self-assessment. They also must pass a national recertification exam every 10 years.

In addition, PAs can be recognized for additional experience and CME in cardiovascular and thoracic surgery (CVTS), by earning a Certificate of Added Qualifications (CAQ) from NCCPA in CVTS. This credential recognizes those certified PAs who have more than 2 years of experience and 150 CME hours focused in the specialty. It also requires a physician attestation and successful passing of a national CVTS specialty exam, which is over and above their recertification exam.

Tips for integration

Across the country, there are many cardiology and cardiac surgery programs that have successfully integrated PAs into the care team. But there is still more to be done in many communities if we are to continue to meet the growing and ever-changing demands. Important steps to take include:

Think beyond traditional models. Whether in a hospital or clinic setting, when developing assignments, think beyond using PAs for simple history and physicals; PAs, especially those with CAQs possess a high level of knowledge and experience and have the ability to work in complex areas ranging from heart transplant teams to cardio-thoracic surgery.
Identify areas of need within the organization and create teams with PAs to address specific challenges such as hospital readmissions, infection control and quality assessments.
Invite PAs to participate with their cardiology and cardiac surgeon colleagues in CME and education programs.
Task PAs with specific responsibilities. They are suited to affect outcomes such as patient education, engaging family members in important steps to take after discharge, and improving satisfaction scores
Encourage communication and collaboration. PAs do not want to be MDs. They chose the profession because they enjoy team-based care and want to make a difference in the lives of patients. If there are misunderstandings surrounding the role of PAs among physicians, initiate a dialogue and find ways to directly address and reconcile their concerns.

Providing solutions

Today’s health care paradigm has to reconcile millions of newly insured Americans with an aging population battling chronic conditions and a shortage of physician specialists. Certified PAs have the education, experience and skills to deliver quality specialty care and satisfied patients.

The next few years will continue to present challenges and changes for our profession. Through closer collaboration with PAs and NPs, we can better serve a growing patient population and make their lives as patients more enjoyable and satisfactory and our lives as busy professionals more rewarding as well.

Joseph Dearani, MD, is chair of cardiovascular surgery at the Mayo Clinic in Rochester, Minn. He is certified by the American Board of Thoracic Surgery – Congenital Cardiac Surgery and the American Board of Surgery. He is current chair of the Workforce on Adult Congenital Heart Surgery for the Society for Thoracic Surgery. Michael Nowak, PA-C, FAASPA, has been a certified cardiothoracic surgery PA for 12 years. He was among the first PAs in the United States to receive the Certificate of Added Qualification in Cardiovascular/Thoracic Surgery. Nowak can be reached at The Mayo Clinic, 200 First St. SW, Rochester, MN 55905 or mnowak333@yahoo.com.

Disclosures: Dearani and Nowak report no relevant financial disclosures.