Patient willingness to be seen by physician assistants, nurse practitioners, and residents in the emergency department: does the presumption of assent have an empirical basis?

Factors influencing the development, recruitment, integration, retention and career development of advanced practice providers in hospital health care teams: a scoping review

BACKGROUND

Advanced practice providers (APPs), including physician assistants/associates (PAs), nurse practitioners (NPs) and other non-physician roles, have been developed largely to meet changing healthcare demand and increasing workforce shortages. First introduced in primary care in the US, APPs are prevalent in secondary care across different specialty areas in different countries around the world. In this scoping review, we aimed to summarise the factors influencing the development, recruitment, integration, retention and career development of APP roles in hospital health care teams.

METHODS

We conducted a scoping review and searched Ovid MEDLINE, Ovid Embase, Ovid Global Health, Ovid PsycINFO and EBSCOhost CINAHL to obtain relevant articles published between Jan 2000 and Apr 2023 that focused on workforce management of APP roles in secondary care. Articles were screened by two reviewers independently. Data from included articles were charted and coded iteratively to summarise factors influencing APP development, recruitment, integration, retention and career development across different health system structural levels (macro-, meso- and micro-level).

RESULTS

We identified and analysed 273 articles that originated mostly from high-income countries, e.g. the US (n = 115) and the UK (n = 52), and primarily focused on NP (n = 183) and PA (n = 41). At the macro-level, broader workforce supply, national/regional workforce policies such as work-hour restrictions on physicians, APP scope of practice regulations, and views of external collaborators, stakeholders and public representation of APPs influenced organisations' decisions on developing and managing APP roles. At the meso-level, organisational and departmental characteristics, organisational planning, strategy and policy, availability of resources, local experiences and evidence as well as views and perceptions of local organisational leaders, champions and other departments influenced all stages of APP role management. Lastly at the micro-level, individual APPs' backgrounds and characteristics, clinical team members' perceptions, understanding and relationship with APP roles, and patient perceptions and preferences also influenced how APPs are developed, integrated and retained.

CONCLUSIONS

We summarised a wide range of factors influencing APP role development and management in secondary care teams. We highlighted the importance for organisations to develop context-specific workforce solutions and strategies with long-term investment, significant resource input and transparent processes to tackle evolving healthcare challenges.

A comparison of the practice patterns of emergency department teams that include physicians, nurse practitioners, or physician assistants

BACKGROUND

Physicians see most emergency department (ED) patients, but, recently, nurse practitioners (NPs) and physician assistants (PAs) have provided an increasing amount of ED care.

PURPOSE

Compare NP and PA teams' practice patterns to physician teams in EDs.

METHODS

Using 12 years of data from the National Hospital Ambulatory Medical Care Survey (2009-2020), we used multivariate regression analysis to separately examine the associations between the ED practice patterns (i.e., number of diagnostic services, number of procedures, waiting time, boarding time, length of visit, and hospital admission) of patients seen by NP or PA teams compared with physician teams.

DISCUSSION

Patient visits to NP and PA teams received fewer diagnostic services and procedures, had shorter visits, and were less likely to be hospitalized.

CONCLUSION

If the additional diagnostic services, procedures, and hospital admission provided by physician teams were unnecessary for the patients studied, NP and PA team care could be more efficient.

Differences in the Patterns of Care Between Emergency Department Visits with and Without a Physician

BACKGROUND

A variety of clinicians practice in emergency departments (EDs). Although most ED patients prefer seeing physicians, a subset sees no physician.

OBJECTIVES

We sought to determine the factors that predict when an ED patient is seen by at least one physician and compared the practice patterns of patient visits seen by at least one physician compared with those seen by no physician.

METHODS

We used 11 years of cross-sectional data from the National Hospital Ambulatory Medical Care Survey and focused on the sample of ED patient visits seen by at least one physician and those seen by no physician. We used bivariate statistics to compare characteristics between samples and used multivariate logistic regression analysis to identify the factors that predicted being seen by a physician. Finally, we compared the practice patterns of patient visits seen by at least one physician compared with those seen by no physician.

RESULTS

Approximately 10% of the sample was not seen by any physician. Patients seen by at least one physician had, on average, 0.8 more diagnostic services ordered/provided and 0.1 more procedures provided compared with patients who were not seen by any physician. Patients seen by at least one physician had longer visits by 29.4 min, on average, and had increased odds of being hospitalized (adjusted odds ratio 3.9, 95% confidence interval 2.9-5.2).

CONCLUSIONS

A variety of patient and hospital characteristics influenced whether ED patients were seen by physicians. Diagnostic services, procedures, visit length, and hospital admission differed by physician presence. Findings have implications for ED practice and future research.

Public experience with and perspectives on medical care provided by PAs

OBJECTIVE

We sought to assess public experiences with and perspectives about physician associates/assistants (PAs), who are taking on increasingly important roles in healthcare.

METHODS

We conducted a survey using a Qualtrics panel assessing whether participants (N = 1,388) received care from PAs, their perceptions of the care received, and their intentions of seeking care from PAs in the future.

RESULTS

About 67% of participants reported receiving care from PAs; 61.7% believed PAs have more time to communicate with patients. Most respondents were satisfied with the care received, said they were likely to see a PA again, and recommended PAs. Of those not treated by PAs, 30.6% were willing to receive care from PAs, 43.8% were willing to receive care from PAs for minor medical needs, 21.3% were unsure, and 4.3% were unwilling. Older participants and those with more education had consistently more favorable views.

CONCLUSIONS

Public experiences with and perceptions of PAs are positive. Future research should employ longitudinal designs to assess trends as the PA workforce continues to grow.

Impact of Beliefs About Local Physician Supply and Self-Rated Health on Willingness to See a Nurse Practitioner During the COVID-19 Pandemic: Web-Based Survey and Experiment

BACKGROUND

The COVID-19 pandemic overburdened primary care clinicians. For nurse practitioners (NPs) to alleviate the burden, the public must be willing to see an NP over a physician. Those with poor health tended to continue seeking care during the pandemic, suggesting that they may be willing to see an NP.

OBJECTIVE

The aim of this study is to evaluate the public's willingness to see an NP for primary care and how this may be associated with their beliefs about the local supply of physicians and self-rated health. Two studies were conducted: (1) a survey to identify correlations and (2) an experiment to assess how willingness is dependent on information about the local supply of physicians.

METHODS

The survey and experiment were conducted digitally in April and December 2020, respectively. Participants were US adults recruited from Amazon's Mechanical Turk platform. The key independent variables were self-rated health, which was a dichotomized 5-point scale (excellent, very good, good vs fair, and poor), and beliefs about local physician supply. The survey measured beliefs about local physician supply, while the experiment manipulated beliefs by altering information the participants read about the local supply of physicians. Willingness to see an NP was assessed in 2 ways. First as an overall preference over a physician and the second as a preference given 2 clinically significant scenarios in which participants imagined they were experiencing either coughing or a headache (presentation order randomized). Multiple regressions and ANOVAs were used to assess how beliefs about the local physician supply and self-rated health were associated with overall willingness to see an NP. Bivariate probits simultaneously estimated willingness to see an NP in the 2 clinically significant scenarios.

RESULTS

The survey showed that concerns about physician supply were associated with lower willingness to see an NP among respondents with comparatively better health but a greater willingness among respondents with comparatively worse health. The experiment suggests that only the latter is causal. For the 2 clinically significant scenarios, these patterns appeared for the coughing scenario in the survey and the headache scenario in the experiment.

CONCLUSIONS

US adults with comparatively worse self-rated health become more willing to see an NP for primary care when they hear information that raises their concerns about the local physician supply. The differences between the survey and experiment results may be useful for interpreting findings from future studies. Findings may aid in managing finite health care resources during public health crises and crafting successful messaging by NP advocacy groups. Efforts to address nursing shortages will also be needed.

US emergency care patterns among nurse practitioners and physician assistants compared with physicians: a cross-sectional analysis

OBJECTIVES

Nurse practitioners and physician assistants (NPs/PAs) increasingly practice in emergency departments (EDs), yet limited research has compared their practice patterns with those of physicians.

DESIGN, SETTING AND PARTICIPANTS

Using nationally representative data from the National Hospital Ambulatory Medical Care Survey (NHAMCS), we analysed ED visits among NPs/PAs and physicians between 1 January 2009 and 31 December 2017. To compare NP/PA and physician utilisation, we estimated propensity score-weighted multivariable regressions adjusted for clinical/sociodemographic variables, including triage acuity score (1=sickest/5=healthiest). Because NPs/PAs may preferentially consult physicians for more complex patients, we performed sensitivity analyses restricting to EDs with >95% of visits including the NP/PA-physician combination.

EXPOSURES

NPs/PAs.

MAIN OUTCOME MEASURES

Use of hospitalisations, diagnostic tests, medications, procedures and six low-value services, for example, CT/MRI for uncomplicated headache, based on Choosing Wisely and other practice guidelines.

RESULTS

Before propensity weighting, we studied visits to 12 410 NPs/PAs-alone, 21 560 to the NP/PA-physician combination and 143 687 to physicians-alone who saw patients with increasing age (41, 45 and 47 years, p<0.001) and worsening triage acuity scores (3.03, 2.85 and 2.67, p<0.001), respectively. After weighting, NPs/PAs-alone used fewer medications (2.62 vs 2.80, p=0.002), diagnostic tests (3.77 vs 4.66, p<0.001), procedures (0.67 vs 0.77, p<0.001), hospitalisations (OR 0.35 (95% CI 0.26 to 0.46)) and low-value CT/MRI studies (OR 0.65 (95% CI 0.53 to 0.80)) than physicians. Contrastingly, the NP/PA-physician combination used more medications (3.08 vs 2.80, p<0.001), diagnostic tests (5.07 vs 4.66, p<0.001), procedures (0.86 vs 0.77, p<0.001), hospitalisations OR 1.33 (95% CI 1.17 to 1.51) and low-value CT/MRI studies (OR 1.23 (95% CI 1.07 to 1.43)) than physicians-results were similar among EDs with >95% of NP/PA visits including the NP/PA-physician combination.

CONCLUSIONS AND RELEVANCE

While U.S. NPs/PAs-alone used less care and low-value advanced diagnostic imaging, the NP/PA-physician combination used more care and low-value advanced diagnostic imaging than physicians alone. Findings were reproduced among EDs where nearly all NP/PA visits were collaborative with physicians, suggesting that NPs/PAs seeing more complex patients used more services than physicians alone, but the converse might be true for more straightforward patients.

Discussing HPV and oropharyngeal cancer in dental settings: gender and provider-type matter

Human papillomavirus (HPV) is the most common sexually transmitted infection in the US and the leading cause of oropharyngeal cancer (OPC), an oral cancer most often identified by dental providers. Given the rise in HPV-associated OPC and recent Food and Drug Administration (FDA) approval of the HPV vaccine to prevent OPC, dental providers have a unique role in HPV prevention. This study assessed US adults' comfort levels discussing HPV and OPC with dental providers. An online survey platform was used to recruit a nationally representative sample of US adults (n = 300). The questionnaire assessed participants' knowledge, acceptability, and comfort discussing HPV-related topics with dental providers. SPSS 24 was utilized for data analyses. In general, participants reported feeling comfortable discussing HPV and OPC with dental providers. Participants reported feeling more comfortable with dentists than dental hygienists when discussing (t = 2.85, p < .01) and receiving recommendations about the HPV vaccine (t = 2.09, p < .05). Participants were less comfortable discussing HPV as a risk factor for OPC compared to non-HPV related risk factors (t = 2.94, p < .01). Female participants preferred female providers, whereas male participants had no preference. Previous research has indicated dental providers recognize their role in HPV prevention, but research is needed to understand patients' perceptions of dental providers' role in HPV prevention. Findings demonstrate that US adults are comfortable discussing HPV and OPC with dental providers, which may be key to OPC-HPV prevention. Future research is needed to facilitate HPV communication between patients and dental providers.

Level of patients' knowledge, confidence, and acceptance regarding the role of residents in a family medicine teaching clinic

BACKGROUND

Although participation of patients is essential for completing the training of medical residents, little is known about the relationships among patients' level of knowledge about the role and responsibilities of medical residents, their confidence in residents' abilities, and their acceptance toward receiving care from residents. The study sought to clarify if and how these three patient-resident relationship components are interrelated.

METHODS

This is a cross-sectional study using a self-administered questionnaire distributed in 2016 to a convenience sample of adult patients (≥ 18 years old) visiting a family medicine teaching clinic. Proportions and chi-square statistics were used to describe and compare groups, respectively.

RESULTS

Of the 471 patients who answered the questionnaire, only 28% were found to be knowledgeable about the role of family medicine residents. Between 54% and 83% of patients reported being highly confident in the ability of residents to perform five routine tasks. Of the patients surveyed, 69% agreed to see a resident during their next appointments. Patients with a high level of confidence in residents' abilities were more likely to agree to see a resident during future appointments (p <0.0001). There was no significant association between level of knowledge and either confidence or acceptance.

CONCLUSIONS

Although the majority of patients had poor knowledge about the role of residents, this was not related to their acceptance of being cared for by residents. A higher level of confidence in residents' ability to perform certain tasks was associated with greater acceptance toward seeing a resident during future appointments.

Patient Acceptance of Nurse Practitioners and Physician Assistants in Rheumatology Care

OBJECTIVE

This study sought to assess whether patients with autoimmune disease would accept advanced practice providers (APPs) as an option to fill the growing shortage of rheumatologists.

METHODS

We administered a cross-sectional survey to 500 patients or parents of children who reported having been diagnosed with qualifying autoimmune conditions and who had seen their primary rheumatology providers in the past 6 months. Respondents self-reported whether their primary providers were rheumatologists or APPs. Our analysis compared the attitude and experience of the patients whose primary rheumatology providers were APPs with those of patients whose primary providers were rheumatologists.

RESULTS

Of respondents, 36.8% reported having APPs as primary rheumatology providers. Patients of APPs were significantly more likely to arrive at their provider's office in 15 minutes or less (p < 0.01) and to be able to schedule routine and urgent appointments sooner (p = 0.02, 0.05). There were no significant differences for overall patient experience of care between provider types. Most patients rated their providers highly, but those who saw rheumatologists rated their providers significantly higher (p < 0.01). APP patients were significantly more likely than rheumatologist patients to prefer to see APPs over rheumatologists (p < 0.01) and to recommend APPs (p < 0.01).

CONCLUSIONS

APPs may improve access to care, and regardless of provider type, patients rated their overall experience of care similarly. Overall, patient attitudes toward APPs were positive regardless of provider type, although APP patients held more positive overall attitudes toward APPs than did rheumatologist patients.

Predictive factors of the general public's willingness to be seen and seek treatment from a nurse practitioner in Australia: a cross-sectional national survey

BACKGROUND

Health care delivery in Australia is experiencing challenges with services struggling to keep up with the increasing demands of an aging population, rising levels of chronic disease and limited funding for care. Where adjunct models of health care such as the Nurse Practitioner (NP) have the potential to address this gap, in Australia, they remain an underutilised service. Clarifying the nature of the consumers 'willingness' to be seen by NPs warrants further investigation.

METHODS

Australia-wide, cross-sectional population-based survey was undertaken using computer-assisted telephone interviewing technique.

RESULTS

While just over 53% of the general public participants (n = 1318) had heard of an NP, once they became aware of their scope of practice, the majority agreed or strongly agreed they were willing to be seen by an NP in the community (91.6%), the emergency department 88.2%), to manage chronic conditions (86%), to have scrips written and referrals made (85.3%), and if they did not have to wait so long to see a medical doctor (81%). Factors significantly predicting willingness were being: female, less than 65 years of age, native English speakers, or residents from town/regional and rural settings.

CONCLUSION

Despite limited awareness of the NP role, a large proportion of the Australian population, across different demographic groups, are willing to be seen and treated by an NP. Expansion of this role to support medical services in areas of need could improve healthcare delivery.

Predictive factors of the general public's willingness to be seen and seek treatment from a nurse practitioner in Australia: a cross-sectional national survey

BACKGROUND

Health care delivery in Australia is experiencing challenges with services struggling to keep up with the increasing demands of an aging population, rising levels of chronic disease and limited funding for care. Where adjunct models of health care such as the Nurse Practitioner (NP) have the potential to address this gap, in Australia, they remain an underutilised service. Clarifying the nature of the consumers 'willingness' to be seen by NPs warrants further investigation.

METHODS

Australia-wide, cross-sectional population-based survey was undertaken using computer-assisted telephone interviewing technique.

RESULTS

While just over 53% of the general public participants (n = 1318) had heard of an NP, once they became aware of their scope of practice, the majority agreed or strongly agreed they were willing to be seen by an NP in the community (91.6%), the emergency department 88.2%), to manage chronic conditions (86%), to have scrips written and referrals made (85.3%), and if they did not have to wait so long to see a medical doctor (81%). Factors significantly predicting willingness were being: female, less than 65 years of age, native English speakers, or residents from town/regional and rural settings.

CONCLUSION

Despite limited awareness of the NP role, a large proportion of the Australian population, across different demographic groups, are willing to be seen and treated by an NP. Expansion of this role to support medical services in areas of need could improve healthcare delivery.

Introducing physician associates to hospital patients: Development and feasibility testing of a patient experience-based intervention

Background

Physician associates (PAs) are one of many new mid‐level health practitioner roles being introduced worldwide. They are a recent innovation in English hospitals. Patient confusion with novel mid‐level practitioner titles and roles is well documented, alongside evidence of a positive association between patients’ ability to identify practitioners and patient satisfaction. No prior research developed an intervention to introduce PAs or any other new practitioner role to hospital patients.

Objective

To develop, with patient and public involvement and engagement (PPIE), an intervention for introducing the PA role to hospital patients, and to test feasibility.

Methods

Intervention development was underpinned by an experience‐based co‐design approach. Workshop participants generated ideas for introducing PAs, subsequently explored in semi‐structured interviews with hospital patients (n = 13). Interview findings were used by participants in a second workshop to design the intervention. Feasibility of the intervention was assessed in relation to its acceptability and efficacy using semi‐structured interviews with hospital patients (n = 20) and PAs (n = 3).

Results

The intervention developed was a patient information leaflet. It was considered feasible to use in the hospital setting, helpful to patients in understanding the PA role and acceptable to both patients and PAs. The intervention was also appreciated by patients for providing reassurance of care and support.

Conclusions

An experience‐based co‐design approach enabled development of an intervention tailored to patients’ experiential preferences. Positive evidence of feasibility and utility is encouraging, supporting future larger‐scale testing.

Patient and public contribution

PPIE representatives were involved in the study design, intervention development and data interpretation.

Reasons for choosing or refusing care from a nurse practitioner: Results from a national population-based survey

AIM

To understand the public's willingness or lack thereof, to be seen and treated by a nurse practitioner (NP) as the first point of contact when accessing healthcare services.

DESIGN

This cross-sectional, population-based survey study used computer assisted telephone interviewing to elicit public opinions on the topic.

METHODS

Data were collected in July and August 2015 from calls randomly placed to Australian households. Survey questions were developed from previous surveys and pilot tested. Summative content analysis was used to analyse open-ended responses.

RESULTS

Most respondents were always, or in some situations, willing to receive care from a nurse practitioner. The main themes identified from those willing to be seen by a nurse practitioner in any situation were, (a) appropriately qualified nurse practitioners, (b) the knowledge and experience to refer on if necessary. Description of situations from those unwilling to be seen by a nurse practitioner related to concern about appropriate care in a life-threatening condition.

CONCLUSION

Respondents unwilling to consider any care from a nurse practitioner or care in an emergency situation, reveal a lack of understanding of their role in the wider healthcare team. As the number of nurse practitioners increase, professional groups and community awareness programmes should be focused on explaining and promoting their essential role.

IMPACT

This study addresses the increasing healthcare requirements of ageing populations through understanding acceptance by society to the provision of care from health professionals other than medical practitioners. Most respondents were willing to be seen by a nurse practitioner for all or most of their healthcare needs. Lack of understanding of their scope of practice and role in the wider healthcare team, particularly in emergency situations, was reflected in responses. Those who would refuse care from a NP were in the minority. Appropriateness and acceptability of the roles of health professionals to provide quality care collaboration need consideration by policy makers.

Consumer preferences regarding physiotherapy practitioners and nurse practitioners in emergency departments - a qualitative investigation

Workforce reform has led to Nurse Practitioners (NP) and Physiotherapy Practitioners (PP) employed in Emergency Departments (ED) to see patients alongside doctors. This qualitative study gathered consumer opinions and preferences regarding NPs, PPs, and doctors, and the attributes desired of them. Twenty-two members of the organization's Consumer Representative Program participated in one of three focus groups which were audio-recorded and transcribed verbatim. Data were subsequently collected using an emergent-systematic design that enabled ideas to be explored and refined in sequential focus groups. Data analysis, utilizing the principles of thematic analysis, identified four themes. First, consumers understand and accept that reform is necessary to improve care, better utilize available resources and create sustainable services. Second, although consumers accept the rationale for employing NPs and PPs, preferences vary regarding who they want as their primary clinician. Some consumers do not mind who provides care as long as they receive the care they need; others believe doctors provide superior care and preferred a doctor; a third group indicated that not everyone who presents to an ED needs to see a doctor and specialized care would be provided by NPs and PPs for certain conditions. Some consumers expressed incomplete or inaccurate understanding of ED staff roles, responsibilities, and skillsets, which influenced their care preferences. Third, consumers identified a core set of desirable staff attributes that apply to everyone irrespective of professional demarcation; all staff should embody these attributes, though the expression of the attributes will vary according to circumstances and the staff member's scope of practice. Fourth, consumers expect effective governance over ED services so that all staff, irrespective of their profession provides safe and effective care. In conclusion, these results can be used by health-care administrators and clinicians to inform workforce reform in EDs, helping to ensure that consumers' opinions and preferences are acknowledged and appropriately addressed.

Advanced Practice Providers in U.S. Urology: A National Survey of Demographics and Clinical Roles

INTRODUCTION

Projections suggest a significant shortage of urologists coupled with an increasing burden of urological disease due to an aging population. To meet this need, urologists have increasingly partnered with advanced practice providers. However, to this point the advanced practice provider workforce has not been comprehensively evaluated. Understanding the impact of advanced practice providers on the urology workforce is essential to maximize collaborative care as we strive for value and quality in evolving delivery models.

METHODS

A 29-item, web based survey was administered to advanced practice providers identified by the AUA (American Urological Association), UAPA (Urological Association of Physician Assistants) and SUNA (Society of Urologic Nurses and Associates), querying many aspects of their practice.

RESULTS

A total of 296 advanced practice providers completed the survey. Advanced practice nurses comprised 62% of respondents while physician assistants comprised the remaining 38%. More than two-thirds of the respondents were female and median age was 46 years. Only 6% reported having participated in formal postgraduate urological training. Advanced practice providers were evenly divided between institutional and private practice settings, and overwhelmingly in urban or suburban environments. The majority of advanced practice providers practice in the ambulatory setting (74%) and characterize their practice as general urology (72%). Overall 81% reported performing procedures independently, with 63% performing some procedures considered to be of moderate or high complexity.

CONCLUSIONS

Advanced practice providers are active in the provision of urological care in many roles, including complex procedures. Given future workforce needs, advanced practice providers will likely assume additional responsibilities. As roles shift we must ensure we have the necessary educational and training opportunities to equip this vital part of our workforce.

Physiologic and Psychologic Risk Factors in Central Serous Chorioretinopathy

PURPOSE

Central serous chorioretinopathy (CSCR) is characterized by macular detachment due to thickened choroid, mostly affecting young men under perceived stress. Although most previous studies on CSCR have been retrospective and have focused on a single facet of the patient's personality, we conducted a prospective, intercontinental, controlled study to analyze the multifaceted personality profile in CSCR.

DESIGN

Prospective, cross-sectional, case-control study.

PARTICIPANTS

Subjects with CSCR from 6 university-based eye clinics consented to participate in a questionnaire. Controls without retinal disease were recruited from the same clinics.

METHODS

The interview consisted of a 60-item questionnaire. Recruitment of participants was from January 2015 to February 2016. Controls were matched for age, gender, and race. Statistical analyses were performed using univariate and multivariate analyses.

MAIN OUTCOME MEASURES

The main parameters registered were presence of stress, daily number of cups caffeine intake, and personality traits (Type A; obsessive-compulsive; aggressive).

RESULTS

A total of 83 consecutive patients with CSCR (mean age, 45.9 years; male, 80.7%) and 83 controls (mean age, 46.0 years; male, 80.7%) were analyzed for 60 variables. Multivariate analysis revealed a strong association with obsessive-compulsive behavior (P = 0.001), caffeine intake (P = 0.002), Type A personality (P = 0.002), continuous stress (P = 0.001), and premature ejaculation (P = 0.001).

CONCLUSIONS

This study sheds light on the unique psychologic functioning of patients with CSCR: preoccupied, inflexible, perfectionist (obsessive-compulsive tendency), competitive, ambitious, impatient, high achiever (Type A personality), and under continuous stress. In addition, caffeine abuse and premature ejaculation were linked to CSCR.

Knowledge and Perceptions of College Students Regarding the Physician Assistant Profession

PURPOSE

Physician assistants (PAs) are nationally certified and state-licensed medical professionals who practice medicine on healthcare teams with physicians and other providers. Despite the increasing popularity and utility of the profession, knowledge of the role of PAs remains scarce among many segments of the population. The purpose of this study was to determine the knowledge and perceptions of the PA profession among undergraduate college students, as well as what factors are associated with better knowledge and perception of the profession.

METHODS

Using a cross-sectional survey, information was gathered regarding knowledge and perception of PAs. A total of 364 students were surveyed from randomly selected undergraduate courses at a Connecticut public university.

RESULTS

Knowledge scores were significantly higher (p<0.05) in older students, female students, those with plans to pursue a healthcare career, those majoring in health and human services, and those satisfied with care received from a PA. Significantly better perceptions (p<0.05) of PAs were found in older students, those with plans for a future career in healthcare, those majoring in health and human services, those who received prior care from a PA, and those who were satisfied with prior care from a PA. After a short educational intervention, improvements in perceptions were statistically significant (p<0.001) in the surveyed population.

CONCLUSION

This study identifies areas of needed improvement in knowledge and perception of PAs and also provides impetus for educational and marketing-based interventions to improve knowledge and perception of the PA profession in the college student population.

Provision of care by medical residents and the impact on quality

The quality of care received by patients is a basic element of modern medicine. Medical residents or interns are essential within the healthcare system, but their lack of experience can raise concerns about the quality of care given. A registrar or specialist has greater knowledge and skills, while a resident has greater motivation and enthusiasm. The aim of training programs is to prepare residents to provide high quality care. This requires close supervision that seems to be lacking, with the consequent impact on both healthcare quality and academic results. The so-called "July effect" refers to the diminished quality of care during the summer months when resident physicians switch over. The results of studies analysing this effect vary widely, but the loss of efficacy during these months does seem to be real. Pulmonology is one of medical specialties that generates the least demand for internships and residencies, but it is impossible to determine if this affects the quality of care. The high prevalence of respiratory diseases and the latest diagnostic and therapeutic advances may mean that this situation will change in coming years.

Why parents use the emergency department during evening hours for nonemergent pediatric care

BACKGROUND

Emergency departments (EDs) are commonly used by pediatric patients for nonemergent reasons. There is little information regarding how parents perceive their use of the ED and primary care availability during evening hours.

METHODS

We conducted a survey of parental perspectives of ED use during evening hours. Participants were parents of pediatric patients (age 0-18 years) at a large quaternary medical center's ED presenting between 17:00 and 22:00 hours from January 15, 2013 to March 12, 2013.

RESULTS

Most patients had a primary care pediatrician (98/102, 96.1%); 80% of their pediatricians (78/98) did not have evening hour availability. Overall, 46.7% of parents would have preferred to go to their primary care pediatrician.

CONCLUSIONS

Many parents who expect outpatient treatment prefer to take their child to a primary care pediatrician during evening hours, but present to the ED because of lack of primary care access.

Mid-level providers and emergency care: let's not lose the force

The progressive rise of ED visits globally, and insufficient numbers of emergency physicians, has resulted in the use of mid-level providers as adjuncts for the provision of emergency care, especially in the US and Canada. Military medics, midwives, aeromedical paramedics, EMT-Ps, flight nurses, forensic nurses, sexual assault nurse examiner nurses--are some examples of well-established mid-level provider professionals who achieve their clinical credentials through accredited training programmes and formal certification. In emergency medicine, however, mid-level providers are trained for general care, and typically acquire emergency medicine skills through on-the-job experience. There are very few training programmes for NPs and PAs in emergency care. The manpower gap for physicians in general, and emergency physicians specifically, will not be eliminated in the reasonable future. Mid-level providers--ENTs, paramedics, NPs, PAs--are an excellent addition to the emergency medicine workforce. However, the specialty of emergency medicine developed because specific and focused training was needed for physicians to practice safe and qualify emergency care. This same principle applies to mid-level providers. Emergency Medicine needs to develop a vision and a plan to train emergency medicine specialist NPs and PAs, and explore other innovations to expand our emergency care workforce.

Ethics of utilizing nurse practitioners and physician's assistants in the dermatology setting

Our current supply of dermatologists in training is insufficient to meet the growing demand for dermatology services. In an era of declining reimbursements and the ever increasing clamor for increased access to care, many practices are turning to nurse practitioners and physician assistants as a cost effective means of fulfilling patient demand. Despite the recommendations of the American Academy of Dermatology, there is no explicit consensus among dermatologists on the educational requirements or appropriate utilization of NPs and PAs in dermatology settings. Colleges of nursing and physician assistant programs recognize the provider demand in dermatology and have begun to implement training programs to address the need for specialty training. Academic settings offer a unique opportunity for NPs and PAs to receive a medically oriented grounding in basic science, dermatopathology, and research.

Are Dutch patients willing to be seen by a physician assistant instead of a medical doctor?

BACKGROUND

The employment of physician assistants (PAs) is a strategy to improve access to care. Since the new millennium, a handful of countries have turned to PAs as a means to bridge the growing gap between the supply and demand of medical services. However, little is known about this new workforce entity from the patient's perspective. The objective of this study was to assess the willingness of Dutch patients to be treated by a PA or a medical doctor (MD) under various time constraints and semi-urgent medical scenarios.

METHODS

A total of 450 Dutch adults were recruited to act as surrogate patients. A convenience sample was drawn from patients in a medical office waiting room in a general hospital awaiting their appointments. Each participant was screened to be naive as to what a PA and a nurse practitioner are and then read a definition of a PA and an MD. One of three medical scenarios was assigned to the participants in a patterned 1-2-3 strategy. Patients were required to make a trade-off decision of being seen after 1 hour by a PA or after 4 hours by a doctor. This forced-choice method continued with the same patient two more times with 30 minutes and 4 hours and another one of 2 hours versus 4 hours for the PA and MD, respectively.

RESULTS

Surrogate patients chose the PA over the MD 96 % to 98 % of the time (depending on the scenario). No differences emerged when analysed by gender, age, or parenthood status.

CONCLUSION

Willingness to be seen by a PA was tested a priori to determine whether surrogate Dutch patients would welcome this new health-care provider. The findings suggest that employing PAs, at least in concept, may be an acceptable strategy for improving access to care with this population.

Update on midlevel provider utilization in U.S. emergency departments, 2006 to 2009

OBJECTIVES

Previous studies have noted a sharp increase in utilization of physician assistants (PAs) and nurse practitioners (NPs), up to 13% of all U.S. emergency department (ED) visits in 2005. The authors sought to reevaluate utilization and visit acuity for these midlevel providers (MLPs) in U.S. EDs from 2006 to 2009.

METHODS

This was a secondary analysis of the 2006-2009 National Hospital Ambulatory Medical Care Surveys (NHAMCS), using the "providers seen" fields to categorize visits. Demographic, visit, and hospital characteristics of visits seen by MLPs only were compared to those seen by MLPs with physician involvement and by physicians only.

RESULTS

Of the estimated 496 million U.S. ED visits from 2006 to 2009, 5.8% (95% confidence interval [CI] = 4.7% to 7.1%) were seen by MLPs only and 7.4% (95% CI = 6.3% to 8.5%) by MLPs with physician involvement. The annual proportions of visits seen by MLPs only for 2006 to 2009 ranged from 5.4% to 6.0% without an obvious trend. Acuity of MLP-only visits in 2006-2009 was similar to prior 1993-2005 data for arrival by ambulance (6.5% vs. 6.0%), urgent/emergent triage acuity (33% vs. 37%), and hospital admission (3.3% vs. 3.0%). From 2006 through 2009, 64% of EDs utilized MLPs, with higher utilization in urban (72%, 95% CI = 64% to 78%) compared to nonurban EDs (51%, 95% CI = 39% to 63%). However, among EDs that did utilize MLPs, nonurban EDs had MLPs without physician involvement see a median 27% of all ED visits, compared to 7.5% for urban EDs.

CONCLUSIONS

Despite a rapid expansion of MLP utilization in U.S. EDs, recent growth appears to have plateaued. The scope of practice of MLPs in EDs does not appear to be rapidly expanding. Urban EDs use MLPs more than nonurban EDs, but among EDs that use MLPs, nonurban EDs had MLPs see a larger proportion of overall ED visits.

Physician Wages in States with Expanded APRN Scope of Practice

In recent years, states have looked to reforms in advanced practice nursing scope of practice (SOP) barriers as a potential means to increase access to primary care while reducing costs. Currently, 16 states and the District of Columbia permit advanced practice registered nurses to practice independently of physicians, allowing them to perform functions such as diagnosing and prescribing under their own authority within the primary care setting. Given the resistance of many physician associations to these reforms, we asked whether the economic interests of primary care physicians might be affected by reforms. Using the Bureau of Labor Statistics data on earnings, we compared primary care physicians' earnings in states that have instituted SOP reforms to those that maintain these practice barriers. We also compared surgeons' earnings as a control group. Lastly, we compared the rate of growth in the earnings of primary care physicians and surgeons over the last ten years. This preliminary analysis revealed no evidence of differences in earnings across the two groups of states.