The first PA program was started at Duke University in 1965 by Dr. Eugene Stead with 4 former Navy core men. The core of the physician assistant profession started with the military and PAs have continued to play an important role in every branch of the armed services, especially in times of combat.
Welcome to the Clinician's Roundtable. I am Lisa D'Andrea Lenell and my guest today is Capt. James Jones to discuss the role of physician assistants in combats and in particular the role they had played in Afghanistan and Iraq.
LISA D'ANDREA LENELL:
Capt. Jones, welcome to ReachMD.
CAPT. JAMES JONES:
Thank you Lisa.
LISA D'ANDREA LENELL:
Capt. Jones, can you describe for us how the army trains enlistees to become army physician assistants?
CAPT. JAMES JONES:
Well, the army uses two sources, we have the Inter Service Physician Assistant Program that trains approximately 80% of our requirements for the military and then we also recruit from the civilian sector from civilian PAs that are in school and those that are practicing to join the active duty team as well as our reserve team toprovide that care.
LISA D'ANDREA LENELL:
Is the training different for physician assistants assigned in military combat zones?
CAPT. JAMES JONES:
The training is different prior to going into a combat zone. The military has a tactical combat medical care course that's in San Antonio that all PAs, and actually all healthcare providers are required to go to before they are deployed to a combat setting that teaches them the roles of the healthcare provider in regards to trauma and how that's going to differ from what you would do in a civilian hospital or even as a paramedic would experience when you are in a deployed setting with other requirements such as maintaining security for that patient and evacuation procedures. So they get an entire course that's design to provide them detailed guidance on how to intubate, how to prevent bleeding, how to prevent shock which is different on a battlefield than it would be if they were injured in New York City, for example.
LISA D'ANDREA LENELL:
How is the medical teams created?
CAPT. JAMES JONES:
The medical team for the PAs, they are the organic asset for military units. Unlike all other branches of the services, the physician assistant serves as the primary care provider and emergency provider within a battalion which is about 800 to 1000 people and that PA is directly responsible for creating the structure for training as well as the requirements for that specific unit when they deploy. Most of the time, you'll have a PA and then a supervising physician that provides guidances as well as there are normal PA model to physician supervision and then they have about 50 medics that are assigned to that unit, that number varies depending on the size of organization and what their mission is, but that's how that particular team is created for the primary care and emergency procedures at that level.
LISA D'ANDREA LENELL:
So there is only one PA per battalion?
CAPT. JAMES JONES:
It depends on the battalion, some battalions have two and even up towards 4 PAs depending on their mission style as well as the number of troops that are assigned, but on average 500 to 1000 soldiers are taken care of by one PA.
LISA D'ANDREA LENELL:
And how many doctors in that group?
CAPT. JAMES JONES:
Generally there is usually one physician that supervises 5 to 6 Army PAs.
LISA D'ANDREA LENELL:
So the medics are the workhorse of the battalion.
CAPT. JAMES JONES:
That is correct.
LISA D'ANDREA LENELL:
And how do the PAs and the medics work together on the team?
CAPT. JAMES JONES:
This is an incredible relationship. They are trained; of course, the training is done by initial phase at Fort Sam Houston, for the medics which is also taught by PAs and then they go to the unit and it is continually reinforced by the training model where the PA works with that medic and continue to enhance their skills at doing checklist and making sure that they have the training as well as the skill sets to execute emergency procedures if they are in a deployed setting, and that relationship serves similar to the way that a PA and a physician work together since that PA supervises all medical aspects of their training as well as their medical care.
LISA D'ANDREA LENELL:
So help us visualize the scene; we are think of M*A*S*H when we think of a combat zone, is there something like that in Iraq and Afghanistan?
CAPT. JAMES JONES:
It's very interesting, the M*A*S*H TV show puts a lot of misnomers out there. There are some similarities in regards to, you know, obviously there is the fun time, there are the hard times, and of course, it's life, and people have all of the same type of issues that you see on M*A*S*H, but the big difference is that the quality of medical care that's offered in deployed setting is very impressive. They have MRI capabilities, CT capabilities, they have neurosurgeons on staff, all of the specialties that you would find at a level I trauma center, you are going to have in a deployed setting, to include lab work and capabilities. Of course, it requires sometimes moving soldiers to that hospital in order to provide that care, however, in most situations the quality of care that that individual would receive is very similar and sometimes even better because of the context of how quick it's provided based on their locations of the injury.
LISA D'ANDREA LENELL:
Could you explain to us the average day for a PA in combat and a PA during peacetime?
CAPT. JAMES JONES:
Okay, well I'll start with the peacetime role, the peacetime role looks that PA is very similar to what a civilian PA does. They generally work Monday through Friday. They put in usually about 45 to 60 hours depending on what is their level of patient load, but that they work in a normal clinic seeing routine patients with a variety of patient load from infant to elderly patients both retirees and activity duty soldiers and their family members get medical care within the system so PAs are exposed to that, but their primary mission is to provide that care to the soldiers which they focus on and also training the medics. So a portion of their day, about 40%, is spent on working with that medic, teaching them skill set and that type of stuff. They generally don't have call, they don't work weekends as a general rule. So they have a very similar lifestyle and then in a deployed setting that situation changes somewhat, but a lot of the things that they do in the garrison environment transfer to the deployed setting. Most people would imagine that the PAs are just seen in trauma all day long which is not the case. In the deployed setting, you are seeing most of it's primary care stuff, the hypertension refills, back pains, knee pains, all of that goes to the deployed setting and then the PA is responsible for providing that, but their hours drastically increase while they are deployed. They generally work 6 days a week and they are long days while they are in their deployed setting and they rotate on emergency care so there will be several PAs and physicians within a team that are providing the care at one location so they will rotate on providing night coverage and day coverage and in some situations where the PA is the provider with the unit that is not near those situations, they are on call all the time while they are deployed so the deployed PA definitely works much harder than they do in the civilian sector, but the type of patients changes only when a trauma patient comes in.
If you are just joining us, you are listening to the Clinician's Roundtable. I am Lisa D'Andrea Lenell and I am speaking with Capt. James Jones, a physician assistant and manager of the Military Physician Assistant Training Program. We are discussing the role of physician assistants assigned to combats zone in the military.
LISA D'ANDREA LENELL:
Capt. Jones when we think about a combat zone, we think about the frontline, are the physician assistants also in the frontline?
CAPT. JAMES JONES:
The physician assistant is, when you talk about where they are placed on a battlefield, frontline in some cases like for Special Forces is different than the most PAs experienced. The mass majority of PAs are in a situation where there is protection around them. They are not exposed to direct fire, examples that an infantry soldier would experience on the front battlefield. However PAs can be exposed to those type of situations and so they are trained to how to handle that, defend themselves and protect their patients, but the mass majority of PAs are set back a mile and half, so it depends on the situation where they would be located from where the actual troops are engaging in some type of conflict that would require healthcare, that's where the combat medic serves primarily.
LISA D'ANDREA LENELL:
So could you tell us about the Qatar PA Trauma Symposium Program?
CAPT. JAMES JONES:
Yes, we had put the trauma symposium together which was an event to bring all of the PAs that were in theater to one occasion to kind of reinforce some of the lessons learnt that the PAs had experienced in various parts of the deployed environment and provide them some additional skills that's from emergency medicine physician and others that had learned a variety of new procedures that would help save patients and get them back to a surgical location to provide definitive care and so that symposium was designed to allow the PAs to come back and talk with each other and also to kind of relax and recover from the long deployed setting, and we utilized that type of trauma symposium not only in encounter, but we also see that in location such as Baghdad, they are doing it throughout the theater and they tried to do at least one or two a year.
LISA D'ANDREA LENELL:
What were the results of the survey?
CAPT. JAMES JONES:
The surveys that were conducted during that trauma symposium were very beneficial to the senior leadership on developing additional training. One of the things that came out of this was the need for a tactical combat medical care course which derived and is now in place, it's taught by physician assistants and they actually teach physicians, nurse practitioners, all healthcare providers that come through the skill sets learned, and many of those developed from that trauma symposium. They also developed and created ways for us to share the lessons learnt and information from the variety of different exposures that the PAs had seen from patient as well as techniques that they had personally developed that seemed to be very effective in the combat deployed setting.
LISA D'ANDREA LENELL:
So, let's talk about the deployment expectations for the PAs in a military. Is it any different than any other enlisted soldiers in the military, they are longer, do they work more hours?
CAPT. JAMES JONES:
They don't necessarily go more than other soldiers, but if you compare them to in the healthcare situation the physician assistant is the third most deployed medical asset and so if you compare that to an infantry soldier, they obviously are the most deployed setting. So, PAs on average can anticipate in a 3-year time frame that they will spend 12 months deployed at the current off tempo with the war going on in Iraq and Afghanistan.
LISA D'ANDREA LENELL:
And let's talk about when they are finished their commitment with the military and if they decide to move on, how do the military PAs integrate into civilian medicine?
CAPT. JAMES JONES:
I think there is a great integration and there are some limitations in regards to understanding the civilian billing cycle and how healthcare insurance works, the military unfortunately, or you could look at it is fortunate depending on which side of the fence you are on. When you are in the military, you don't have to worry about who is paying for the medications and lab tests and things like that and I think if there is a challenge for military trained PAs who go into the civilian sector initially, there is a large learning curve for them to develop that skill set and that's the most common reported limitation. I think clinically they feel very confident in going forward and developing a clinical practice that's you know conducive to the civilian sector and I think that portion of it, but the major concern is understanding how to get reimbursement and to help the civilian practice prosper because in the military of course you don't have to worry about that.
LISA D'ANDREA LENELL:
The civilian PAs can't figure that out either.
CAPT. JAMES JONES:
It's a challenge.
LISA D'ANDREA LENELL:
Do the army trained physician assistants work in the VA hospitals?
CAPT. JAMES JONES:
They do, there is a large percentage of them that elect to take on a role within the VA and continue providing service, which is fantastic, but there is also a large percentage that move away from the military service altogether and do other things.
LISA D'ANDREA LENELL:
I would like to thank our guest Capt. Jones and all of the military medical professionals for taking care of our American Heroes.
I am Lisa D'Andrea Lenell and you have been listening to the Clinician's Roundtable on ReachMD XM160, The Channel for Medical Professionals.
Please visit our website at www.reachmd.com which features our entire library through on-demand podcasts and thanks for listening.
