PAs and NPs Can Help Your Practice

So why are so few working in ophthalmology?

By Jerry Helzner, Senior Editor

A clever wordsmith has come up with a catch phrase for the aging of the baby boomer generation: “the silver tsunami.” Of all the medical specialties, eye care may be the most impacted by almost 80 million Americans reaching their senior years, as many common eye problems are closely associated with age.

With demand for eye care about to dramatically increase, reimbursement treading water, and the number of ophthalmologists in active practice not growing, it's imperative that new ways be found to provide superior patient care for tens of millions of seniors in a cost-effective manner.

The answer is likely to be found in the growing ranks of physician assistants (PAs) and nurse practitioners (NPs).

If PAs and NPs are, indeed, the answer, why hasn't anyone asked the obvious question: What's taking so long for ophthalmology to discover the value of these highly trained professionals who can take over many of the tasks ophthalmologists now perform and that optometrists are not licensed to do?

Here, I will describe the training that PAs and NPs undergo and the key roles they can play in an ophthalmology practice. I'll also answer the question as to why many ophthalmology practices have been reluctant to hire these medical professionals in the past.

A Focus on Primary Care

First, a brief introduction to the nature of the training for PAs and NPs and some statistics for the two specialties.

Both PAs and NPs are trained in a primary care model. PAs are trained in a physician-centered model and NP training follows a nursing model. PA training constitutes a basic 27-month course in a master's degree program at one of the 163 institutions in the United States that offer the degree. Together, these programs graduate approximately 6,000 new PAs each year.

Ann C. Davis, senior director for state advocacy and outreach for the American Academy of Physician Assistants (AAPA), says PA candidates come from a variety of backgrounds, including the military, lab technicians, EMTs and other previous medical experience.

“The average age of a graduating PA is about 27,” notes Ms. Davis. “For the vast majority this is a second career, which means they are mature and have already had a great amount of life experience.”

About 75% of PAs will work in some form of primary care, where they serve as so-called “physician extenders.” They are capable of performing a wide range of highly skilled tasks, including some aspects of surgery, with the important provision that they must be working under physician supervision. The supervision must be either direct or through immediate telecommunication consultation.

Nurse Practitioner Training

According to Mary Jo Goolsby, EdD, MSN, director of research and education for the American Academy of Nurse Practitioners (AANP), about 350 nurse practitioner training programs exist in the United States, and they graduate about 11,000 new NPs each year. These are generally master's degree programs of 24- to 30-months duration and require the individual to have a bachelor's degree and be a registered nurse prior to entering. The average student entering NP training already has 10 years of medical experience, almost always in the role of registered nurse.

“Our records do not show many NPs currently working in ophthalmology,” Dr. Goolsby says. “However, that could easily change in the future as NPs have the type of skills that could make a great contribution to an ophthalmology practice. Doing histories and physicals, playing a key role in patient education, assisting in surgery — these are all roles that an NP could fill very well.”

Why PAs and NPs Fit Now

Until recently, only a small number of ophthalmology practices reported employing PAs or NPs. However, the value of using these practitioners, especially in high-volume surgical practices, increased greatly in 2009 when CMS mandated a comprehensive history and physical (H&P) on every patient undergoing a surgical procedure, no matter how minor.

For a practice such as Barnet Dulaney Perkins, which operates eight ASCs in Arizona, this meant that H&Ps had to be done for 15,000 surgical cases each year, including 3,500 YAG capsulotomies. This constituted too great a workload for the practice physicians, so Imelda Kelly, RN, surgical administrator and director of nursing for the practice, studied Arizona state regulations for practitioners and found a solution in four newly hired PAs who could handle the basic H&Ps. The surgeon still performs the pre-surgical check of the heart and lungs.

Other practices that have hired PAs, both in general ophthalmology and retina, provide glowing reviews for their overall contributions. Some PAs have even been specially trained to open and close in cataract surgery, a use of PAs pioneered by James Gills, MD, of St. Luke's Cataract & Laser Institute in Tampa, Fla.

Practices that use PAs for surgical tasks would be wise, as a precautionary measure, to include that information on their informed consent form. Malpractice defense lawyers concur that wording such as “this procedure will be performed by the surgeon and qualified associates and/or assistants of his or her choice” should be sufficient to meet the standard of informed consent.

Even in retina, where procedures tend to be more complex than routine cataract surgery, a few practices have used PAs for years to assist in and facilitate surgery.

Doing H&Ps and handling surgical tasks are beyond the scope of practice of optometrists, who generally are paid more that PAs and NPs. PAs and NPs both make an average of about $90,000 per year.

“The numbers of PAs working in ophthalmology practices is definitely increasing,” Ms. Davis says. “I would estimate that we now have several hundred PAs in ophthalmology.”

Specialized Training Could Help

One of the major reasons some ophthalmology practices have thus far been reluctant to hire PAs and NPs is because PA and NP training is highly focused on primary care. The graduates from these programs do require intense on-the-job training to be successfully employed in a specialty such as ophthalmology.

“We see great value in a generalist training program,” Ms. Davis says. “As a specialty practice, you will have to spend time getting the PA up to speed.”

However, PA and NP programs are starting to recognize that some additional specialty training can be of value in making their graduates appealing to more types of employers.

“Some PA programs, such as Cornell and UAB [University of Alabama, Birmingham] now have a surgical focus,” Ms. Davis says. “I know of one program in Utah with a pediatric focus.”

Ms. Davis says PAs in training can use internships and clinical rotations they can choose as electives to obtain specialized training in a field that interests them, such as ophthalmology.

Tony Brenneman, MPAS, PA-C, president of the Physician Assistant Education Association, says that specialized clinical rotations vary in length and can take place in an ophthalmology practice setting or in an academic health center as long as the legal paperwork to qualify the site is completed.

“This is a great way for a PA student to be introduced to ophthalmic care and an equally great way for an ophthalmologist to have experience working with a PA,” Mr. Brenneman says. “These clinical rotations have often served as a pathway to future employment, with both the PA and supervising physician finding that they are comfortable and productive working with each other.”

Mr. Brenneman also notes that the primary care training of a PA transfers well into many aspects of eye care, especially in the monitoring of systemic conditions and diseases that can affect the eye.

“We don't expect that a great number of PAs will choose to go into a specialty because the needs for primary-care practitioners are so great right now,” Mr. Brenneman says, but ophthalmology is one of the specialized areas where PAs are a great fit in the team approach to care that will become more and more prevalent.”

Additional Training for NPs

As for specialized training for NPs, Dr. Goolsby notes that NPs can focus their clinical rotations on a specialty area if they so choose. They can also take post-graduate courses in specific specialties.

“An ophthalmology practice can offer a preceptorship to an NP in training and have that individual receive on-the-job training even prior to graduation,” Dr. Goolsby says. “In that instance, the NP could come into the practice with some specific experience in eye care.”

Dr. Goolsby also notes that, in many respects, providing eye care is quite complementary to primary care (for example, managing patients with diabetes), so that the transition from primary care training to working in an ophthalmology practice can be relatively seamless.

“I think in areas such as educating patients and taking H&Ps, the nurse practitioner can step right in and make a valuable contribution to an ophthalmology practice,” she asserts.

Inquire Before You Hire

State regulations define the scope of practice of PAs and NPs. Check with state authorities and regulators to determine if a PA or an NP might be the better choice for your practice.

For example, some states allow NPs to work independently; other states specify that NPs must work in collaboration with a physician, and still others mandate that NPs be under the direct supervision of a physician. A requirement for an NP to have a nationally recognized credential is another area where states differ.

In addition to checking with state healthcare regulators, it is a good idea to talk with members of practices that already employ PAs or NPs or both. Ophthalmology Management has found that almost all practices employing PAs and NPs speak positively about their skills, maturity, commitment and cost-effectiveness. OM