Table Of ContentWe dedicate this text to PA students:
past, present, and future.
You inspire us with your curiosity, motivation,
and commitment to patient care.
We hope that this project will contribute to
your education, and that you will use it to contribute to
the lives and well-being of your patients.
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PHYSICIAN ASSISTANT: A GUIDE TO CLINICAL PRACTICE ISBN: 978-1-4160-4485-7
Copyright © 2008, 2003, 1999, 1994 by Saunders, an imprint of Elsevier Inc.
All rights reserved. No part of this publication may be reproduced or transmitted in any
form or by any means, electronic or mechanical, including photocopying, recording,
or any information storage and retrieval system, without permission in writing from the
publisher. Permissions may be sought directly from Elsevier’s Rights Department:
phone: (+1) 215 239 3804 (US) or (+44) 1865 843830 (UK); fax: (+44) 1865 853333;
e-mail: [email protected]. You may also complete your request on-line via
the Elsevier website at http://www.elsevier.com/permissions.
Notice
Knowledge and best practice in this fi eld are constantly changing. As new research and
experience broaden our knowledge, changes in practice, treatment and drug therapy may
become necessary or appropriate. Readers are advised to check the most current information
provided (i) on procedures featured or (ii) by the manufacturer of each product to be
administered, to verify the recommended dose or formula, the method and duration of
administration, and contraindications. It is the responsibility of the practitioner, relying on
their own experience and knowledge of the patient, 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 Editors assume any
liability for any injury and/or damage to persons or property arising out of or related to any
use of the material contained in this book.
The Publisher
Library of Congress Cataloging-in-Publication Data
Physician assistant : a guide to clinical practice / [edited by] Ruth Ballweg º [et al.]. — 4th ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 987–1–4160–4485–7
1. Physicians’ assistants. 2. Clinical competence. I. Ballweg, Ruth.
[DNLM: 1. Physician Assistants—United States. 2. Clinical Competence—United States.
3. Delivery of Health Care—methods—United States. 4. Professional Role—United States.
W 21.5 P5775 2008]
R697.P45P48 2008
610. 73¢72069—dc22 2007041274
Acquisitions Editors: Rolla Couchman, Druanne Martin
Developmental Editor: John Ingram
Publishing Services Manager: Linda Van Pelt
Design Direction: Gene Harris
Cover Designer: Gene Harris
Marketing Managers: William Veltre, Helena Mutak
Printed in Canada
Last digit is the print number: 9 8 7 6 5 4 3 2 1
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Contributors
Diane Dixon Abercrombie, PA-C, MA, MMSc J. Dennis Blessing, PhD, PA-C
Assistant Professor and Academic Coordinator Associate Dean for South Texas Programs
Department of Physician Assistant Studies School of Allied Health Sciences
University of South Alabama Professor and Chair
Mobile, Alabama Department of Physician Assistant Studies
The University of Texas Health Science Center at
Linda G. Allison, MD, MPH Antonio
San Antonio, Texas
Professor and Chair
Department of Physician Assistant Studies
Le Moyne College Wallace D. Boeve, EdD, MSPA, PA-C
Syracuse, New York Program Director
Physician Assistant Studies
David P. Asprey, PhD, PA-C Grand Valley State University
Grand Rapids, Michigan
Associate Professor and Program Director
Physician Assistant Program
The University of Iowa Carver College of Medicine Anthony Brenneman, MPAS, PA-C
Physician Assistant Clinical Assistant Professor and Director of
Department of Pediatric Cardiology Clinical Education
University of Iowa Children’s Hospital Physician Assistant Program
Iowa City, Iowa The University of Iowa Carver College of Medicine
Iowa City, Iowa
Patrick C. Auth, PhD, PA-C
Program Director Darwin Brown, MPH, PA-C
Hahnemann Physician Assistant Program Assistant Professor
Drexel University Physician Assistant Program
Philadelphia, Pennsylvania University of Nebraska
Omaha, Nebraska
Ruth Ballweg, MPA, PA-C
Associate Professor David R. Buck†
Director, MEDEX Northwest
Division of Physician Assistant Studies Geraldine A. Buck, MHS, PA-C
University of Washington School of Medicine
Associate Professor and Director
Seattle, Washington
Advanced Physician Assistant Program
College of Nursing and Health Professions
Diana P. Barr, BA Drexel University
Associate Director Philadelphia, Pennsylvania
Health Information Management Department
The University of Texas Medical Branch at Tom Byers
Galveston
Former Deputy Mayor
Galveston, Texas
Seattle, Washington
†Deceased.
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vi Contributors
James L. Cary, PA-C, MHA Nicole Gara, MA
Senior Partner Vice President
Medical Legal Education and Consulting Government and Professional Affairs
Cary and Associates, LLC American Academy of Physician Assistants
Panama City, Florida Alexandria, Virginia
R. Monty Cary, PA-C, MEd F. J. (Gino) Gianola, PA
Senior Partner Lecturer
Medical Legal Education and Consulting MEDEX Northwest
Cary and Associates, LLC Division of Physician Assistant Studies
Las Vegas, Nevada University of Washington School of Medicine
Seattle, Washington
R. Scott Chavez, PhD, MPA, PA, CCHP-A
Anita Duhl Glicken, MSW
Vice President
National Commission on Correctional Professor of Pediatrics
Health Care Interim Director
Chicago, Illinois Child Health Associate Physician Assistant
Program
John L. Chitwood, LTCOL, USAF, BSC University of Colorado at Denver Health Sciences
Center
Assistant Professor
Aurora, Colorado
Interservice Physician Assistant Program
Saint Francis University
Constance Goldgar, MS, PA-C
Loretto, Pennsylvania
Associate Director
Dan Crouse, MPAS, PA-C Physician Assistant Program
University of Utah
Director of Academic Affairs
Salt Lake City, Utah
University of Utah Physician Assistant Program
Department of Family and Preventive Medicine
J. Kirkland Grant, MD, FACOG
Salt Lake City, Utah
Chairman
Linda M. Dale, MSOD, PA-C Department of Obstetrics and Gynecology
Mesquite Community Hospital
Physician Assistant
Mesquite, Texas
Occupational Medicine
WorkCARE, PLLC
Jim Hammond, MA, PA-C
Wenatchee, Washington
Professor and Director
Ann Davis, MS, PA-C Physician Assistant Program
James Madison University
Director of State Government Affairs
Harrisonburg, Virginia
American Academy of Physician Assistants
Alexandria, Virginia
Kenneth R. Harbert, PhD, CHES, PA-C
Walter A. Eisenhauer, MMS, MEd, PA-C Dean
School of Physician Assistant Studies
Professor and Director
South College
Physician Assistant Studies
Knoxville, Tennessee
Lock Haven University
Lock Haven, Pennsylvania
Virginia McCoy Hass, FNP-C, PA-C, MSN
Timothy C. Evans, MD, PhD, FACP Faculty
Department of Family and Community Medicine
Associate Professor of Medicine
FNP/PA Program
Department of Medicine
University of California, Davis
University of Washington
Sacramento, California
Seattle, Washington
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Contributors vii
Ky Haverkamp, PA-C Kathy A. Kemle, MS, PA-C
Lecturer Assistant Professor
MEDEX Northwest Department of Family Medicine
Division of Physician Assistant Studies Mercer University School of Medicine
University of Washington School of Medicine Physician Assistant
Physician Assistant Department of Family Medicine
Family Practice Medical Center of Central Georgia
Group Health Macon, Georgia
Seattle, Washington
Timothy J. King, PA-C
Lawrence Herman, MPA, PA-C Faculty
Assistant Professor/Senior Clinical Coordinator Southwest Georgia Area Health Education Center
Department of Physician Assistant Studies Albany Area Primary Health Care, Inc.
New York Institute of Technology Albany, Georgia
Old Westbury, New York
William C. Kohlhepp, DHSc, PA-C
L. Jill Jones-Hester, PA-C Assistant Professor of Physician Assistant
Physician Assistant Education
North Texas Infectious Disease Consultants Director, ELMPA Program
Dallas, Texas Quinnipiac University
Hamden, Connecticut
Roderick S. Hooker, PhD, PA-C Physician Assistant
Occupational Health Plus
Associate Professor
Hospital of Saint Raphael
Division of Rheumatic Diseases
New Haven, Connecticut
Department of Medicine
The University of Texas Southwestern Medical
Center Kristine J. Kucera, PA-C, MPAS, DHS
Director of Rheumatology Research Adjunct Clinical Professor
Medical Services, Rheumatology Section Physician Assistant Studies
Department of Veterans Affairs The University of Texas Southwestern Medical
Dallas VA Medical Center Center
Dallas, Texas Physician Assistant
Texas Dermatology Associates
Steven Johnson, PA-C Dallas, Texas
Physician Assistant
Palo Alto Medical Foundation David H. Kuhns, PA-C, MPH
Palo Alto, California Assistant Professor
Physician Assistant Program
Bryanne L. Jones, MA College of Health Professions
University of New England
Senior Research and Legislative Associate
Portland, Maine
Compassion and Choices
Portland, Oregon
Barbara Coombs Lee, PA, FNP, JD
P. Eugene Jones, PhD, PA-C President
Compassion and Choices
Editor-in-Chief
Portland, Oregon
Journal of Physician Assistant Education
Professor and Chair
Department of Physician Assistant Studies Paul Lombardo, MPS, RPAC
The University of Texas Southwestern Medical Program Chair
Center Department of Physician Assistant Education
Dallas, Texas University of Stony Brook
Stony Brook, New York
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viii Contributors
H. James Lurie, MD Vyjeyanthi S. Periyakoil, MD
Associate Professor Director, VA Genetics Clinic
MEDEX Northwest Associate Director, VA Hospice Care Center
Division of Physician Assistant Studies Palo Alto VA Health Care System
University of Washington School of Medicine Palo Alto, California
Seattle, Washington
Martha Peterson, MPH, PA-C
H. William MaHaffy, PA-C Assistant Professor and Academic Coordinator
Physician Assistant Department of Physician Assistant
Division of Cardiothoracic and Vascular Surgery Rangos School of Health Sciences
Evangelical Medical Services Organization Duquesne University
Evangelical Community Hospital Pittsburgh, Pennsylvania
Lewisburg, Pennsylvania
Michael L. Powe, BS
Steven Meltzer, BHS, PA-C Director
Director, Rural Outreach and Eastern Washington Health Systems and Reimbursement Policy
Education Programs American Academy of Physician Assistants
MEDEX Northwest Alexandra, Virginia
Division of Physician Assistant Studies
University of Washington School of Medicine Sharon R. Powell, RHIA
Spokane, Washington
Facility Product Manager for Print Products
Ingenix
Mindy G. Milton, PA-C, MPA Salt Lake City, Utah
Faculty
Department of Family and Community Medicine Michael A. Rackover, PA-C, MS
FNP/PA Program
Program Director and Associate Professor
University of California, Davis
Physician Assistant Program
Sacramento, California
Philadelphia University
Philadelphia, Pennsylvania
Dawn Morton-Rias, EdD, PA-C
Dean and Assistant Professor Richard R. Rahr, EdD, PA-C
College of Health Related Professions
Professor and Chair
SUNY Downstate Medical Center
Department of Physician Assistant Studies
New York, New York
School of Allied Health Sciences
The University of Texas Medical Branch at
Debra S. Munsell, MPAS, PA-C Galveston
Assistant Professor Galveston, Texas
Department of Physician Assistant Studies
School of Allied Health Science Maryann Ramos, MPH, PA-C
The University of Texas Medical Branch at
Adjunct Assistant Professor of Health Care
Galveston
Sciences
Galveston, Texas
Physician Assistant Program
George Washington University School of Medicine
Donald M. Pedersen, PhD, PA-C and Health Sciences
Professor and Director Physician Assistant
Department of Family and Preventive Medicine DiLorenzo Tricare Health Clinic at the Pentagon
University of Utah Walter Reed Army Medical Center
Salt Lake City, Utah Washington, DC
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Contributors ix
Paul S. Robinson, PA-C Howard O. Straker, PA-C, MPH
Speaker of the House of Delegates and Vice Director
President Community Medicine—Physician Assistant
American Academy of Physician Assistants Program
Physician Assistant Department of Health Care Services
Metropolitan Urologic Specialists Assistant Professor
St. Paul, Minnesota Department of Prevention and Community Health
George Washington University School of Medicine
Albert Simon, PA-C and Health Sciences
Washington, DC
Associate Professor and Chair
Department of Physician Assistant Studies
A. T. Still University Ernst L. Stump, MSW, ACSW
Mesa, Arizona Assistant Director/Behavioral Scientist
Altoona Family Physicians Family Medicine
Anna Mae Smith, MPAS, PA-C Residency
Altoona Regional Health System
Academic Coordinator
Altoona, Pennsylvania
Physician Assistant Program
Lock Haven University
Lock Haven, Pennsylvania Edward M. Sullivan, MS, PA-C
Physician Assistant
Lisa K. Southwick, PA-C, MPAS J. Kirkland Grant Obstetrics and Gynecology
Practice
Assistant Professor
Mesquite, Texas
Physician Assistant Program
College of Health Professions
University of New England Mary Vacala, ATC, MSPAS, PA-C
Portland, Maine Physician Assistant
Orthopaedics
P. Michel Statler, MLA, PA-C Chatham Orthopaedics
Savannah, Georgia
Associate Director
Associate Professor
Physician Assistant Program Daniel Vetrosky, PA-C, MEd
Midwestern University Assistant Professor
Glendale, Arizona Department of Physician Assistant Studies
University of Southern Alabama
Sherry Stolberg, MGPGP, PA-C Mobile, Alabama
Consultant
Adjunct Associate Professor Durward A. Watson, PA-C
Drexel University Physician Assistant Program Private Infectious Disease Practice
Lincoln, Massachusetts Dallas, Texas
Henry W. Stoll, PA-C Emily WhiteHorse, PA-C, MA
Senior Lecturer Associate Program Director
MEDEX Northwest Joint MSPAS/MPH Program
Division of Physician Assistant Studies Touro University—California
University of Washington School of Medicine Vallejo, California
Seattle, Washington
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x Contributors
Keren H. Wick, PhD Gwen Yeo, PhD
Director of Research and Graduate Programs Co-Director
MEDEX Northwest Stanford Genetic Education Center
Division of Physician Assistant Studies Stanford University School of Medicine
University of Washington School of Medicine Palo Alto, California
Seattle, Washington
Chantelle M. Wolpert, MBA, PA-C, GC
Physician Assistant and Genetic Counselor
Center for Human Genetics
Duke University Medical Center
Durham, North Carolina
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Foreword
Thirty-one years ago doctors were in short During this time I was building a house with
supply. Nurses were even scarcer. The old model my own hands. I could use a wide variety of
of the doctor, a receptionist, and a laboratory materials and techniques in my building.
technician was inadequate to meet the needs of I refl ected on how inadequate my house would
our increasingly complex society. Learning time be if I was restricted to only four materials. The
had disappeared from the schedule of the busy doctor restricted to a very slim support system
doctor. The only solution that the overworked could never build a practice adequate to meet
doctor could envisage was more doctors. Only a the need of modem medicine. He or she needed
doctor could do doctors’ work. The lengthy more components in the system. The physician
educational pathway (college, medical school, assistant was born!
internship, residency, and fellowship) must Nurses, laboratory technicians, and other
mean that only persons with a doctor’s educa- health professionals were educated in their own
tion could carry out a doctor’s functions. schools, mostly hospital related. The new practi-
I examined in some detail the actual practice tioner (the PA) was to be selected, educated, and
of medicine. After sampling the rich diet of med- employed by the doctor. The PA—not being
icine, most doctors settled for a small area. If geographically bound to the management system
the offi ce was set up to see patients every 10 to of the hospital, the clinic, or the doctor’s offi ce—
15 minutes and to charge a certain fee, the prac- could oscillate between the offi ce, the hospital,
tice conformed. If the outcome was poor, or if the operating room, and the home.
the doctors recognized that the problem was too A 2-year curriculum was organized at Duke
complex for this pattern of practice, the patient Medical School with the able assistance of
was referred. Dr. Harvey Estes, who eventually took the
Doctors seeing patients at half-hour or 1-hour program under the wing of his department of
intervals also developed practice patterns and set Family and Community Medicine. The object of
fee schedules to conform. The specialists tended the 2-year course was to expose the student to
to treat diseases and leave the care of patients to the biology of humans and to learn how doctors
others. Again, they cycled in a narrow path. rendered services. On graduation, PAs had
The average doctors developed very effi cient learned to perform many tasks previously done
patterns of practice. They operated 95% of only by licensed doctors and could serve a useful
the time in a habit mode and rarely applied a role in many types of practices. They performed
thinking cap. Because they did everything that those tasks that they could do as well as their
involved contact with the patients, time for doctor mentors. If the mentor was wise, the PA
family, recreation, reading, and furthering their mastered new areas each year and increased his
own education disappeared. or her usefulness to the practice.
Why this intense personalization of medical Setting no ceilings and allowing the PA to
practice? All doctors starting practices ran grow have made this profession useful and satis-
scared. They wanted to make their services fying. Restricting PAs to medical supervision has
essential to the well-being of their patients. They given them great freedom. Ideally, they do any
wanted the patient to depend on them alone. part of their mentors’ practice that they can do
After a few years in this mode, they brainwashed as well as their mentors.
themselves and actually believed that only they The PA profession has certainly established
could obtain information from the patient and itself and is recognized as a part of the medical
perform services that involved physical contact system. PAs will be assuming a larger role in the
with the patient. care of hospital patients as physician residency
xi
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xii Foreword
programs decrease in size. As hospital house We all owe a debt of gratitude to the fi rst fi ve
staff, PAs can improve the quality of care for students who were willing to risk 2 years of their
patients by providing continuity of care. lives to enter a new profession when there was
Because of the close association with the little support from doctors, nurses, or govern-
doctor and patient and the varied duties of the ment. From the beginning, patients responded
PAs, they have an intimate knowledge of the way favorably, and each PA gained confi dence and
of the medical world. They know patients, they satisfaction from these interactions. Patients
are aware of the triumphs and failures of medi- made and saved the profession. We hope that
cine; they know how doctors think and what every new PA will acknowledge this debt and
they do with information collected about continue the excellent work of the original fi ve.
patients. For these reasons, they are in demand
by all businesses that touch the medical profes- EUGENE A. STEAD, JR, MD
sion. One of the fi rst fi ve Duke students recently FLORENCE MCALISTER PROFESSOR
earned a doctoral degree in medical ethics and EMERITUSOF MEDICINE
is working in education. The world is open, and DUKE UNIVERSITY MEDICAL CENTER
PAs are grasping their share. DURHAM, NORTH CAROLINA
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