Editorial by Todd J. Cohen, MD: Every year I have a number of summer research interns working in Winthrop-University Hospital’s electrophysiology (EP) laboratory. Typically, most of these students are interested in pursuing a career as a physician. This year, one of the students, Monica Mitrache, is considering a career as a physician assistant. Her father, Alexandru Mitrache, has worked with me for nearly 19 years as my personal physician assistant (Figure 1). Monica has been shadowing her father in the lab this summer, and has written a short article on the role of physician assistants in EP. Physician assistants (and nurse practitioners, for that matter) have played a major role in our laboratory, and have provided a consistent core infrastructure (along with nursing and other EP staff). They are versatile, enthusiastic, and energetic. I hope you enjoy the article!

When exploring career options within the healthcare field, there are many different routes one can take in order to find the profession that is right for them. For example, those taking the medical school route (for physicians and surgeons) are eventually awarded with a professional degree. There are also other career options that do not require participation in medical school but still allow hands-on experience in the healthcare field. One of those options is becoming a Physician Assistant (PA).

A PA is a highly skilled healthcare professional who is licensed to practice medicine as part of a team, along with physicians and other healthcare providers. An important factor regarding this profession is that PAs can perform tasks previously done only by physicians. Some of these tasks include history taking, physical examinations, diagnosis, consults, and patient management. The Physician Assistant title differs from that of nursing in that nursing is far more clinically based, although PAs and nurse practitioners carry many similar and interchangeable qualities. They are prepared both academically and clinically to perform such tasks under the supervision of a doctor of medicine (MD) or a doctor of osteopathic medicine (DO). In order to become a PA, most programs require four years of an undergraduate education with the attainment of a Bachelor’s degree. Following those four years, the aspiring PA will partake in a Physician Assistant program for two years until they are officially licensed.

In the mid 1960s, educators and doctors recognized that there was a shortage of primary care physicians in the healthcare field. As a result, the first Physician Assistant training program was founded in 1965 — fifty years ago — by Dr. Eugene A. Stead, Jr. at Duke University. The first PA students were mostly military medics or personnel; in fact, the first graduates of the program were Navy hospital corpsmen who had received intensive medical training during their service.¹ These first students were able to take knowledge and experience from the military and apply it to a role in primary healthcare. Over the years, the profession started to become much less dominated by males, and today about 58 percent of PAs are women.²

A PA is regulated at two different levels: they are licensed at a state level according to its specific laws, and they need to establish certification through a national organization. This national organization, known as the American Association of Physician Assistants (AAPA), was established in 1975 as an independent organization to administer a certification program.² As per state regulations, a law that is seen across all states regarding PAs is that they must have a supervising doctor. Depending on the task, the supervising physician does not necessarily need to be at the same location of the PA — sometimes telephone communications with periodic site visits will suffice. Often, the supervising physician and PA will have a supervising plan, which is then filed with state agencies.

In terms of settings in which PAs practice, the environments vary greatly. A PA can practice in any setting in which a physician provides care to patients. The most common practice areas include general surgery, surgery specialties, and emergency medicine. Some PAs are also involved in teaching, administration, research, and other non-clinical roles.²

The EP setting is one in which a PA can thrive. The main focus regarding the studies and procedures performed in the EP lab revolves around the mechanisms and therapies of cardiac arrhythmias. There are many different procedures within this branch of physiology in which a PA would have a significant role.

For example, one condition often seen in the EP lab is syncope of unknown etiology. EP testing typically involves a tilt table study, which is used to decipher whether or not a patient has neurocardiogenic syncope, orthostatic hypotension, or autonomic dysfunction. Neurocardiogenic syncope is a condition that occurs when a person has an abnormal response to stimulation of the nervous system; it involves a temporary loss of consciousness associated with a drop in atrial blood pressure, followed by a decrease in heart rate. After the patient is securely strapped onto the exam table, the job of the PA is to monitor the activity of the patient’s heart rate and blood pressure, and look for any sudden decreases in either category. If the tilt table test fails to reveal any evidence of neurocardiogenic syncope or orthostatic hypotension, the next step would be to undergo an EP study.

The goal of an EP study is to evaluate the heart’s conduction system and check if there are any inducible arrhythmias, which may represent the etiology of the patient’s syncope. Unlike the tilt table study, an EP study is an invasive procedure that involves small, thin wire electrodes being inserted through a vein in the groin. The role of a PA during an EP study involves obtaining venous or arterial access using these wires and also placing catheters in different regions of the heart. If the EP study shows no evidence of arrhythmia or conduction disease, the next step would be to insert an implantable loop recorder under the skin of the chest. This device is a dual-electrode, paper-clip sized electrocardiographic monitoring device that can be injected underneath the skin, typically alongside the sternum. It is used for diagnosing patients who have unexplained palpitations or syncope as well as for long-term monitoring of patients at risk for or with previously documented atrial fibrillation. The PA, when trained and credentialed, can assist with this procedure by making a small incision and injecting the device while under the supervision of the attending physician.

Another major role of the PA working in electrophysiology is to participate in the implantation of cardiac devices. The PA will work with the attending physician when implanting devices such as a pacemaker or an implantable cardioverter defibrillator. After the operation, the PA typically sees the patient in follow-up and looks for signs of bleeding, swelling, or infection. They will commonly authorize prescriptions, return calls to patients, and see patients and their families while making rounds at the hospital.

Outside of their participation in the lab, the PA is also involved in clinical or office work. This consists of evaluating new patients, performing consults with them, and checking up on previous patients. They will often brief new patients on information regarding what is done in the EP lab and why, and work at the doctor’s discretion on whether or not the patient qualifies for any of the procedures or studies. Another task for a PA during office or clinical work consists of monitoring and evaluating the need for anticoagulation therapy. A patient undergoing anticoagulation therapy, especially warfarin, requires close monitoring of his or her INR. The task for the PA in this situation is to titrate the amount of warfarin required to maintain a therapeutic INR level.

For a long time, physicians and surgeons carried a large amount of responsibilities and tasks on their own in regards to evaluating and helping their patients. While they still hold the most significant role in patient care, they now have the support and help of the physician assistant in both the lab and office. A PA is not only beneficial to their supervising physician, but also plays an important role in the well-being of the patient and helps to guide their medical management. Although their role may vary in terms of what field the PA is working in, the career itself is a great asset to the world of healthcare.

References

1. American Academy of Physician Assistants. Available online at: https://www.aapa.org/. Accessed August 5, 2015.
2. Vorvick, Linda. Physician Assistant Profession (PA). MedlinePlus / U.S. National Library of Medicine. Published August 11, 2013. Available online at https://www.nlm.nih.gov/medlineplus/ency/article/001935.htm. Accessed August 5, 2015.