The challenges of increasing access to rheumatology care, managing chronic rheumatic diseases, and improving practice efficiency are daunting. In 2007, the Rheumatology Workforce Study highlighted the existing critical shortage of rheumatologists, and the anticipated dramatic shortages by 2025.1
Physician assistants (PAs) have historically augmented the healthcare workforce for family medicine, but in recent years PAs have become part of many surgical and medical subspecialty teams.2 There are only a few one-year postgraduate rheumatology PA fellowships offered in the U.S. The vast majority of rheumatology PAs gain their experience with on-the-job rheumatology training. Currently, 9% of the ARHP membership consists of PAs, but this likely only represents a subset of rheumatology PAs working in clinical practice.
Selecting a PA and developing goals for incorporating one into a rheumatology practice are important decisions. Most PA candidates have prior clinical experience; however, not all PA experiences lend themselves to the practice of rheumatology. Experience in primary care with the management of chronic disease appears to be an optimal background for transition to rheumatology. The use of a PA in a rheumatology practice should be tailored to their primary care strengths in noninflammatory musculoskeletal disease, performing procedures, managing stable rheumatic diseases, and routine new patient consultations.3,4
The clinical environment for a PA’s on-the-job training varies greatly between academic and private practice. Regardless of the setting, there is a significant learning curve for PAs that can only be reduced with a dedicated commitment to teaching with supervision, especially in the first six months of practice. An academic rheumatology practice with residents and fellows is a natural learning environment to integrate PAs into clinic since the same learning objectives and goals are emphasized for the PAs, residents, and fellows.
In the early months of training, it is imperative to emphasize learning and documenting the rheumatologic review of systems, musculoskeletal examination, assessment of disease activity, diagnosis, and disease management. An electronic medical record with a template note is a useful learning tool for all aspects of documentation. Ongoing supplemental reading is essential for appropriate recommended topics and will enrich the PA’s depth of knowledge of rheumatic diseases, disease-modifying antirheumatic drugs, and biologic therapies.
In a practical sense, a PA new to rheumatology will work in close collaboration with an assigned rheumatologist. The initial PA clinic schedule should be lighter than that of a full-time provider to facilitate time for mentoring. Screening initial patient consultations for new PAs and integrating continuity patients into a PA’s schedule can manage both the workload and complexity of patients seen by the PA. This enables quality supervision for new patients, provides an opportunity to teach about chronic disease and management, and is an effective strategy for on-the-job training. As PAs gain experience and improve their efficiency each month, their clinic appointment schedule can progressively approach that of a fully trained PA or rheumatologist. Once our PA colleagues are fully integrated into practice, they can be very effective providers, team oriented, and loyal to the rheumatology mission and our patients.