Table Of ContentPHYSICIAN
ASSISTANT
A Guide to Clinical Practice
SIXTH
EDITION
Ruth Ballweg, MPA, PA-C Emeritus, DFAAPA
Professor Emeritus
Department of Family Medicine
University of Washington School of Medicine
Seattle, Washington
Director of International Affairs
National Commission on Certification of Physician Assistants
Johns Creek, Georgia
Darwin Brown, MPH, PA-C, DFAAPA
Physician Assistant Educator
Omaha, Nebraska
Daniel T. Vetrosky, PhD, PA-C, DFAAPA
Associate Professor (Ret.) and Part Time Instructor
University of South Alabama
Department of Physician Assistant Studies
Pat Capps Covey College of Allied Health Professions
Mobile, Alabama
Tamara S. Ritsema, MPH, MMSc, PA-C/R
Assistant Professor
Department of Physician Assistant Studies
George Washington University School of Medicine and Health Sciences
Washington, DC
Adjunct Senior Lecturer
Physician Assistant Programme
St. George’s, University of London
London, United Kingdom
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
PHYSICIAN ASSISTANT: GUIDE TO CLINICAL PRACTICE,
SIXTH EDITION ISBN: 978-0-323-40112-8
Copyright © 2018 by Elsevier, Inc. All rights reserved.
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Notices
Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical treatment
may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluat-
ing and using any information, methods, compounds, or experiments described herein. In using such
information or methods they should be mindful of their own safety and the safety of others, including
parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the
most current information provided (i) on procedures featured or (ii) by the manufacturer of each prod-
uct to be administered, to verify the recommended dose or formula, the method and duration of admin-
istration, and contraindications. It is the responsibility of practitioners, relying on their own experience
and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for
each individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors,
assume any liability for any injury and/or damage to persons or property as a matter of products liability,
negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas
contained in the material herein.
Library of Congress Cataloging-in-Publication Data
Names: Ballweg, Ruth, editor. | Brown, Darwin, editor. | Vetrosky, Daniel T.,
editor. | Ritsema, Tamara S., editor.
Title: Physician assistant : guide to clinical practice / [edited by] Ruth
Ballweg, Darwin Brown, Daniel T. Vetrosky, Tamara S. Ritsema.
Other titles: Physician assistant (Ballweg)
Description: Edition: sixth. | Philadelphia, PA : Elsevier, [2017] | Includes
bibliographical references and index.
Identifiers: LCCN 2016053047 | ISBN 9780323401128 (pbk. : alk. paper)
Subjects: | MESH: Physician Assistants | Clinical Competence | Professional
Role | Delivery of Health Care--methods | United States
Classification: LCC R697.P45 | NLM W 21.5 | DDC 610.7372069--dc23 LC record available at
https://lccn.loc.gov/2016053047
Content Strategist: Sarah Barth
Content Development Specialist: Joan Ryan
Publishing Services Manager: Patricia Tannian
Project Manager: Ted Rodgers
Design Direction: Patrick Ferguson
Printed in United States of America
Last digit is the print number: 9 8 7 6 5 4 3 2 1
C
ontributors
David P. Asprey, PhD, BA, BS, MA Anthony Brenneman, MPAS, PA-C
Professor and Program Director Director and Associate Professor
Physician Assistant Program Department of Physician Assistant Studies and
College of Medicine, University of Iowa Services
Iowa City, Iowa Carver College of Medicine
University of Iowa
Ruth Ballweg, MPA, PA-C Emeritus, DFAAPA
Iowa City, Iowa
Professor Emeritus
Darwin Brown, MPH, PA-C, DFAAPA
Department Family Medicine
University of Washington School of Medicine Formerly Assistant Professor
Seattle, Washington University of Nebraska Medical Center
Director of International Affairs Physician Assistant Program
National Commission on Certification of Physician Omaha, Nebraska
Assistants
Michelle Buller, MMS, PA-C
Johns Creek, Georgia
Academic Director/Associate Professor
Kate Sophia Bascombe, BSc, PGDip
Physician Assistant Studies Program
Teaching Fellow Union College
Physician Associate Studies Lincoln, Nebraska
St. George’s University of London
Reamer L. Bushardt, PharmD, PA-C, DFAAPA
Physician Associate
General Practice Senior Associate Dean for Health Sciences
Glebe Road Surgery Professor, Department of Physician Assistant Studies
London, United Kingdom George Washington University School of Medicine
and Health Sciences
Wallace Boeve, EdD, PA-C
Washington, DC
Professor
Robin N. Hunter Buskey, DHSc, MPAS, PA-C
Program Director
Physician Assistant Program Senior Physician Assistant
Bethel University U.S. Department of Justice
St. Paul, Minnesota Federal Bureau of Prisons Medical Center
Butner, North Carolina
Jonathan M. Bowser, MS, PA-C
Jill Cavalet, MHS, PA-C
Associate Dean of Physician Assistant Studies at the
School of Medicine Clinical Associate Professor
Associate Professor of Pediatrics Physician Assistant Department
Program Director of the Child Health Associate Saint Francis University
Physician Assistant Program Loretto, Pennsylvania
University of Colorado School of Medicine
Jeff W. Chambers, PA-C
Denver, Colorado
Physician Assistant
St. Mary’s Health Care System
Athens Regional Medical Center
Athens, Georgia
v
vi Contibutors
Torry Grantham Cobb, MPH, MHS, DHSc, Christine Everett, PhD, MPH, PA-C
PA-C
Assistant Professor
Dartmouth Medical School Duke Physician Assistant Program
Hanover, New Hampshire Department of Community and Family Medicine
Dartmouth-Hitchcock Medical Center Duke University School of Medicine
Lebanon, New Hampshire Durham, North Carolina
Roy H. Constantine, PA-C, MPH, PhD Jennifer Feirstein, MSPAS, PA-C
Assistant Director of Mid-Level Practitioners Clinical Coordinator and Assistant Professor
St. Francis Hospital–The Heart Center Department of Physician Assistant Studies
Roslyn, New York A.T. Still University
Professor of Health Sciences Mesa, Arizona
Trident University International
Christopher P. Forest, MSHS, PA-C, DFAAPA
Cypress, California
Director of Research
Marci Contreras, MPAS, PA-C
Assistant Professor of Clinical Family Medicine
Assistant Professor Keck School of Medicine
Physician Assistant Studies University of Southern California
University of Texas Medical Branch at Galveston Division of Physician Assistant Studies
(UTMB) Primary Care Physician Assistant Program
Galveston, Texas Alhambra, California
Dan Crouse, MPAS, PA-C April Gardner, MSBS, PA-C
Assistant Professor Assistant Professor
Department of Family and Preventive Medicine Program Director and Academic Coordinator
Director of Clinical Evaluation, Division of Department of Physician Assistant Studies
Physician Assistant Studies University of Toledo
University of Utah Toledo, Ohio
Salt Lake City, Utah
Constance Goldgar, MS, PA-C
Ann Davis, MS, PA-C
Associate Professor
Vice President, Constituent Organization Outreach University of Utah Physician Assistant Program
and Advocacy Salt Lake City, Utah
American Academy of Physician Assistants
Earl G. Greene III
Alexandria, Virginia
Managing Attorney
Justine Strand de Oliveira, DrPH, PA-C,
Law Offices of Idleman and Greene
DFAAPA Omaha, Nebraska
Professor
Noelle Hammerbacher, MS
Vice Chair for Education
Department of Community and Family Medicine Freelance Examination Editor/Technical Writer
Professor, Duke School of Nursing Philadelphia, Pennsylvania
Affiliate Faculty, Duke Global Health Institute
Virginia McCoy Hass, DNP, FNP-C, PA-C
Duke University School of Medicine
Durham, North Carolina Assistant Clinical Professor
Former Director, Nurse Practitioner Program
Sondra M. DePalma, MHS, PA-C, CLS, Former Interim Director, Physician Assistant Program
DFAAPA, AACC Betty Irene Moore School of Nursing
Assistant Director of Advanced Practice Family Nurse Practitioner and Physician Assistant
Penn State Milton S. Hershey Medical Center Programs
Physician Assistant and Clinical Lipid Specialist Sacramento, California
Penn State Hershey Heart and Vascular Institute
Hershey, Pennsylvania
Contibutors vii
Erin Hoffman, MPAS, PA-C Bri Kestler, MMS, PA-C
Assistant Professor Assistant Professor
Department of Physician Assistant Education Department of Physician Assistant Studies
University of Nebraska Medical Center University of South Alabama
Omaha, Nebraska Mobile, Alabama
Trenton Honda, MMS, PA-C William C. Kohlhepp, DHSc, PA-C
Director and Assistant Clinical Professor Professor of Physician Assistant Studies
Physician Assistant Program Dean, School of Health Sciences
Northeastern University Quinnipiac University
Boston, Massachusetts Hamden, Connecticut
Theresa Horvath, MPH, PA-C, DFAAPA David H. Kuhns, MPH, PA-C, CCPA, DFAAPA
Program Director Consultant on International Physician Assistant
Physician Assistant Institute Education
University of Bridgeport Advisor to the University of Aberdeen (Scotland)
Bridgeport, Connecticut Physician Assistant Program
Advisor to the Royal College of Surgeons in Ireland
Hannah Huffstutler, PA-C, MHS
Advisor to the European Physician Assistant
Assistant Professor Cooperative (EuroPAC)
Physician Assistant Studies Adjunct Faculty, Arcadia University Physician
University of South Alabama Assistant Program
Pat Capps Covey College of Allied Health Glenside, Pennsylvania
Professions
Luppo Kuilman, MPA
Mobile, Alabama
Program Manager
Emily Joy Jensen, MMSc, PA-C
Master Physician Assistant Program
Surgical and Inpatient Physician Assistant School of Health Care Studies
Piedmont Transplant Institute Hanze University of Applied Sciences, Groningen
Piedmont Atlanta Hospital The Netherlands;
Atlanta, Georgia Adjunct Professor
Department of Physician Assistant Studies
James C. Johnson III, MPAS, PA-C
College of Health and Human Services
Assistant Professor Northern Arizona University
Department of Physician Assistant Studies Phoenix, Arizona
High Point University
Barbara Coombs Lee, JD, FNP
Congdon School of Health Sciences
High Point, North Carolina President
Compassion and Choices
Gerald Kayingo, PhD, PA-C
Denver, Colorado
Director for the Master of Health Services-Physician
Susan LeLacheur, DrPH, PA-C
Assistant Program
Assistant Clinical Professor Associate Professor of Physician Assistant Studies
Betty Irene School of Nursing at University of School of Medicine and Health Sciences
California, Davis The George Washington University
Sacramento, California Washington, DC
Kathy A. Kemle, MS, PA-C Jason Lesandrini, PhD(c)
Assistant Professor Executive Director of Medical and Organizational
Family Medicine Ethics, Wellstar Health System
Mercer University Adjunct Faculty, Department of Physician Assistant
Macon, Georgia Studies, Mercer University, Atlanta, Georgia
Adjunct Faculty, Department of Physician Assistant
Studies, Philadelphia College of Osteopathic
Medicine, Suwanee, Georgia
viii Contibutors
Rebecca Maldonado, MSHPE, PA-C Debra S. Munsell, DHSC, PA-C, DFAAPA
Associate Program Director Associate Professor
Child Health Associate/Physician Assistant Program Program Director, Master of Physician Assistant
University of Colorado Studies Program
Denver, Colorado Louisiana State University Health Sciences Center
New Orleans, Louisiana
Erin Nicole Lunn McAdams, PA-C, MHS
Lillian Navarro-Reynolds, MS, PA-C
Assistant Professor
Department of Physician Assistant Studies Assistant Professor
University of South Alabama Physician Assistant Program
Pat Capps Covey College of Allied Health Oregon Health Sciences University
Professions Portland, Oregon
Mobile, Alabama
Kevin Michael O’Hara, MMSc, MS, PA-C
Nancy E. McLaughlin, MHA, DHSc, PA-C
Assistant Professor
Assistant Professor Physician Associate Program
Department of Physician Assistant Studies Yale School of Medicine
Philadelphia College of Osteopathic Medicine New Haven, Connecticut
Philadelphia, Pennsylvania
Courtney J. Perry, PharmD
Steven Meltzer, BA, BHSc, PA-C
Assistant Professor
Director, Outreach and Eastern Washington Department of Physician Assistant Studies
Education Programs Wake Forest School of Medicine
MEDEX Northwest Physician Assistant Program Winston-Salem, North Carolina
University of Washington
Ron W. Perry, MS, MPAS, MEd,
Spokane, Washington
DFAAPA, PA-C
Anthony A. Miller, MEd, PA-C
Program Director, Interservice Physician Assistant
Professor and Director Program (IPAP)
Division of Physician Assistant Studies Graduate School, Health Readiness Center of
Shenandoah University Excellence
Winchester, Virginia Army Medical Center & School, Joint Base San
Antonio
Margaret Moore-Nadler, DNP, RN
San Antonio, Texas
University of South Alabama
Maura Polansky, MS, MHPE, PA-C
College of Nursing
Community Mental Health Program Director, Curriculum Development,
Mobile, Alabama Department of Clinical Education
Program Director, Office of Physician Assistant
Dawn Morton-Rias, EdD, PA-C
Education
President and CEO The University of Texas MD Anderson Cancer
National Commission on Certification of Physician Center
Assistants Houston, Texas
Johns Creek, Georgia
Michael L. Powe, BS
Karen Mulitalo, MPAS, PA-C
Vice President, Reimbursement and Professional
Associate Professor Advocacy
Program Director American Academy of Physician Assistants
Division of Physician Assistant Studies Alexandria, Virginia
Department of Family and Preventive Medicine
Brenda Quincy, PhD, MPH, PA-C
University of Utah School of Medicine
Salt Lake City, Utah Associate Professor
College of Pharmacy and Health Sciences
Butler University
Indianapolis, Indiana
Contibutors ix
Michael Rackover, MS, PA-C Craig S. Scott, PhD
Theodore C. Search Emeritus Professor Professor of Biomedical Informatics and Medical
Physician Assistant Program Education
Philadelphia University University of Washington School of Medicine
Philadelphia, Pennsylvania Seattle, Washington
Stephanie M. Radix, JD Freddi Segal-Gidan, PhD, PA-C
Senior Director, Constituent Organization Outreach Assistant Clinical Professor of Neurology and
and Advocacy Gerontology
American Academy of Physician Assistants University of Southern California (USC) Keck
Alexandria, Virginia School of Medicine
Los Angeles, California
Scott D. Richards, PhD, PA-C, DFAAPA
Director of Rancho/USC California Alzheimer’s
Founding Chair and Director Disease Center (CADC)
Department of Physician Assistant Studies Rancho Los Amigos National Rehabilitation Center
School of Health Sciences Downey, California
Emory & Henry College
Edward M. Sullivan, MS, PA-C
Marion, Virginia
Physician Assistant
Robin Risling-de Jong, PA-C, MHS
J. Kirkland Grant Obstetrics and Gynecology Practice
Assistant Professor Sunnyvale, Texas
Department of Physician Assistant Studies
Stephane VanderMeulen, MPAS, PA-C
University of South Alabama
Mobile, Alabama Associate Professor
Founding Program Director
Tamara S. Ritsema, MPH, MMSc, PA-C
Physician Assistant Program
Assistant Professor Creighton University School of Medicine
George Washington University School of Medicine Omaha, Nebraska
and Health Sciences
Daniel T. Vetrosky, PhD, PA-C, DFAAPA
Washington, DC
Associate Professor (Ret.) and Part Time Instructor
Elizabeth Rothschild, MMSc, PA-C
University of South Alabama
Assistant Professor Department of Physician Assistant Studies
Physician Assistant Division Pat Capps Covey College of Allied Health
Department of Family and Preventive Medicine Professions
Emory University School of Medicine Mobile, Alabama
Atlanta, Georgia
Lisa K. Walker, MPAS, PA-C
Barbara Saltzman, PhD, MPH
Director, Physician Assistant Studies Program
Assistant Professor Massachusetts General Hospital Institute of Health
Public Health and Preventive Medicine Professions
University of Toledo College of Medicine and Life Boston, Massachusetts
Sciences
Natalie Walkup, MPAS, PA-C
Toledo, Ohio
Assistant Professor
Patty J. Scholting, MPAS, MPH, PA-C
Associate Program Director
Assistant Professor Department of Physician Assistant Studies
Physician Assistant Program University of Toledo
University of Nebraska Medical Center Toledo, Ohio
Omaha, Nebraska
Jennifer B. Wall, MSPAS, PA-C
Assistant Professor
Department of Physician Assistant Studies
The George Washington University
Washington, D.C.
x Contibutors
Chantelle Wolpert, PhD, MBA, PA-C, GC Joseph Zaweski, MPAS, PA-C
Assistant Professor and Research Coordinator Assistant Dean and Program Director
Department of Physician Assistant Studies Physician Assistant Program
School of Health Sciences School of Nursing and Health Professions
Emory & Henry College Valparaiso University
Marion, Virginia Valparaiso, Indiana
Johnna K. Yealy, MSPAS, PA-C Olivia Ziegler, MS, PA
Physician Assistant Program Director Assistant Chief, Academic Affairs
University of Tampa Physician Assistant Education Association
Tampa, Florida Washington, DC
Gwen Yeo, PhD
Director Emerita, Senior Ethnogeriatric Specialist
Stanford Geriatric Education Center
Stanford University School of Medicine
Stanford, California
F
oreword
Thirty-one years ago, doctors were in short sup- needed more components in the system. The physi-
ply. Nurses were even scarcer. The old model of cian assistant (PA) was born!
the doctor, a receptionist, and a laboratory tech- Nurses, laboratory technicians, and other health
nician was inadequate to meet the needs of our professionals were educated in their own schools,
increasingly complex society. Learning time had which were mostly hospital related. The new prac-
disappeared from the schedule of the busy doc- titioner (the PA) was to be selected, educated, and
tor. The only solution that the overworked doctor employed by the doctor. The PA—not being geo-
could envisage was more doctors. Only a doctor graphically bound to the management system of the
could do doctors’ work. The lengthy educational hospital, the clinic, or the doctor’s office—could
pathway (college, medical school, internship, resi- oscillate between the office, the hospital, the operat-
dency, and fellowship) must mean that only persons ing room, and the home.
with a doctor’s education could carry out a doctor’s A 2-year curriculum was organized at Duke Medi-
functions. cal School with the able assistance of Dr. Harvey
I examined in some detail the actual practice of Estes, who eventually took the program under the
medicine. After sampling the rich diet of medicine, wing of his department of Family and Community
most doctors settled for a small area. If the office was Medicine. The object of the 2-year course was to
set up to see patients every 10 to 15 minutes and to expose the student to the biology of human beings
charge a certain fee, the practice conformed. If the and to learn how doctors rendered services. On
outcome was poor, or if the doctors recognized that graduation, PAs had learned to perform many tasks
the problem was too complex for this pattern of prac- previously done by licensed doctors only and could
tice, the patient was referred. serve a useful role in many types of practices. They
Doctors seeing patients at half-hour or 1-hour performed those tasks that they could do as well as
intervals also developed practice patterns and set their doctor mentors. If the mentor was wise, the PA
fee schedules to conform. The specialists tended to mastered new areas each year and increased his or
treat diseases and leave the care of patients to others. her usefulness to the practice.
Again, they cycled in a narrow path. Setting no ceilings and allowing the PA to grow
The average doctors developed efficient patterns have made this profession useful and satisfying.
of practice. They operated 95% of the time in a habit Restricting PAs to medical supervision has given
mode and rarely applied a thinking cap. Because them great freedom. Ideally, they do any part of their
they did everything that involved contact with the mentors’ practice that they can do as well as their
patients, time for family, recreation, reading, and mentors.
furthering their own education disappeared. The PA profession has certainly established itself
Why this intense personalization of medical prac- and is recognized as a part of the medical system. PAs
tice? All doctors starting practices ran scared. They will be assuming a larger role in the care of hospital
wanted to make their services essential to the well- patients as physician residency programs decrease
being of their patients. They wanted the patient to in size. As hospital house staff, PAs can improve the
depend on them alone. After a few years in this mode, quality of care for patients by providing continuity
they brainwashed themselves and actually believed of care.
that only they could obtain information from the Because of the close association with the doctor
patient and perform services that involved physical and patient and the PAs’ varied duties, PAs have an
contact with the patient. intimate knowledge of the way of the medical world.
During this time I was building a house with my They know patients, they are aware of the triumphs
own hands. I could use a wide variety of materials and failures of medicine, and they know how doctors
and techniques in my building. I reflected on how think and what they do with information collected
inadequate my house would be if I were restricted to about patients. For these reasons, they are in demand
only four materials. The doctor restricted to a slim by all businesses that touch the medical profession.
support system could never build a practice adequate One of the first five Duke students recently earned
to meet the needs of modern medicine. He or she a doctoral degree in medical ethics and is working in
xi
