The appearance in January of a paper suggesting that practices employing NPs did better in diabetes care than did practices employing PAs or employing only physicians caused quite a furor in the PA world. The PA profession, on a roll lately in terms of positive public relations, was not quite ready to deal with an inconvenient finding.

The purpose of the study, published in the Annals of Family Medicine, was to examine the quality of diabetes care among family practices employing NPs, PAs or neither. The results showed that practices that employed NPs did the best job.¹

The Short-Term Response

The PA profession's immediate reaction was to attack the study and attempt to discredit its findings. While understandable, such a reaction makes the profession appear defensive and prickly. While it may well be, as AAPA President Gregor F. Bennett, MA, PA-C, said in his official letter of response,² that "To insinuate that NPs or PAs 'influenced' the quality of diabetes care is a misstatement," and that the authors' conclusions were unsupported by the study's design in that it could not demonstrate the connection of patients to a particular clinician, such objections ring hollow once the horse is out of the barn.

Clearly, like all studies, this one has flaws, and Bennett is serving the profession well to register objection. But it is in a sense pointless to hammer it-the damage has been done. More important than attempting to criticize and refute the study, we should consider how we should strengthen our profession's research base. Instead of attacking papers such as this, the PA profession would be better served if it used this occasion to initiate research of its own on the profession.

The Long-Term Response

As we all know, there is a dearth of studies, particularly recent ones, that detail the characteristics and advantages of using PAs in a variety of clinical settings. Even the more recent papers are secondary analyses of large existing databases and are not direct examinations of PA clinical practice activities. The literature that affirms the effectiveness of PAs in various practice settings is disturbingly old.

Would it not be nice if, when a negative report appears in the literature, the PA profession had in its quiver positive studies that demonstrate the effectiveness of PAs working in, shall we say, diabetes care? The NP profession in the past decade has done a credible job of performing studies that examine the performance aspects of NPs, particularly as they relate to chronic diseases.

Rather than condemn this paper and its findings, which is tempting and perhaps satisfying for us to do, we should realize that this study's publication points out the need for the PA profession to promote (meaning fund) the performing of studies that emphasize the positive attributes of employing PAs in practices that treat patients with chronic diseases.

While the Research Grants Program, co-sponsored by the AAPA and the Physician Assistant Education Association, is alive and healthy, it offers would-be researchers only a $20,000-a-year maximum to conduct projects on PA practice and utilization.³ As anyone in health services research knows, this is a drop in the bucket in a world in which a well-designed clinical trial assessing provider characteristics easily can run in the seven figures. There are also little moneys available from federal sources or from private philanthropy for health services research in general and on workforce topics in particular. It comes down to this fact: If the PA profession is going to produce studies on PA practice characteristics and effectiveness, it likely will need to underwrite them.

PA Research Is Vital

This circumstance should serve as a wake-up call for the PA profession, that there is a need for us to continue to demonstrate our effectiveness in practice. The essential way to do this is by performing studies that demonstrate (ideally, the positive) characteristics of PA practice. Such studies need to be current. Other health professions have moved forward in this direction and have used research findings to their advantage in workforce policy discussions.

Many areas are ripe for examination: What are the advantages of using PAs in practices that treat mostly chronic diseases? Are aspects of PA-physician teams different from physician-only services in certain practice settings? What are the clinical and economic advantages of using PAs on inpatient hospital services?

Research has been a controversial topic within the AAPA, with many opinions but little consensus on how to fund, conduct and promote projects that would examine PA practice aspects. But there should be little disagreement with the now clear need for the PA profession to produce evidence confirming what we all believe to be the positive attributes of utilizing PAs in a variety of clinical practice settings.

James F. Cawley is professor and interim director of the PA program at the School of Medicine and Health Sciences at The George Washington University in Washington.

References

1. Ohman-Strickland PA, Orzano AJ, Hudson SV, et al. Quality of diabetes care in family medicine practices: influences of nurse-practitioners and physician's assistants (sic). Ann Fam Med. 2008;6(1):14-22.

2. Bennett GF. Letter to Kurt Stange, MD, PhD, editor, Annals of Family Medicine. January 18, 2008. http://www.aapa.org/afm-response.pdf. Accessed February 14, 2008.

3. AAPA/PAEA Research Grants Program. http://www.paeaonline.org/Grants/AAPAPAEAGrantsProgram.htm. Accessed February 14, 2008.

To access the complete archives of James F. Cawley's column in ADVANCE, go to www.advanceweb.com/pa and click on "Inside the PA Profession" under "columns."