The medical staff for the general surgical unit at Anne Arundel Medical Center can be seen each morning huddled at the nurses' station, where they discuss how patients fared overnight and what needs to be addressed during the day.
Decision are made. Charts are updated. Patients are tended.
The rhythm is largely the same as any other unit at the medical center, or similar units in other hospitals. The difference is that those coordinating the care at the Arundel hospital — called hospitalists — are primarily physician assistants, not doctors, as is customary.
The move to hand off the responsibilities of hospitalists — physicians who specialize in hospital medicine— to those with a general medical training and not extensive doctor's education, was born of a need to improve efficiency and reduce health care costs, officials at the Anne Arundel hospital said. It also frees up a limited supply of doctors to handle the most complex cases and to support the physician assistants on the front line.
The medical center's move to give physician assistants such autonomy pushes the limits of a trend that began years ago to hand off work traditionally done by doctors to physician assistants, nurses and other medical personnel. The movement gained steam as millions of previously uninsured people received health insurance under the federal Affordable Care Act, and it isn't likely to abate even if the law is significantly altered, those in the field say.
"What we did was probably more forward-thinking," said Dr. Timothy M. Capstack, a physician hospitalist and Anne Arundel Medical's chief of the division of internal medicine. "The model seems to be very effective."
Capstack, who is also regional medical director for the company that staffs the surgery unit at the hospital and units in more than a dozen other Maryland medical facilities, recently tested the model against another hospital unit that is primarily run by physicians. He found there wasn't much difference in patient outcomes, evidence enough to continue operating in this way and perhaps spur other hospitals to rethink how they deploy staff, he said.
A report on the study, published in October's Journal of Clinical Outcomes Management, showed no significant difference over 18 months in 2012 and 2013 in patient mortality, hospital readmissions, lengths of stay and consults with specialists such as cardiologists when care was led by physician assistants compared with doctors.
Under the model, physician assistants are paired with physicians, who see patients every three days and are available to answer questions from physician assistants. The physician assistants see about a dozen patients daily.
Dr. Henry Michtalik, an assistant professor of medicine at the Johns Hopkins University's School of Medicine and senior author of the report, said that the research focused on a single center and that more research is needed to prove that health outcomes are similar and there are cost savings from shifting work to physician assistants, particularly if the trend continues as expected.
Physician assistants and other non-physician clinicians have been expanding their roles in many ways, inside and outside hospitals, he said. Michtalik called it "working to the top of their licenses," or doing all the jobs they are legally allowed, not just the ones initially assigned to them, such as assisting doctors or doing paperwork.
Patients now may see a physician assistant instead of a doctor not only in a hospital but when they go to see their family physician or some specialists.
"We know there have been a lot of challenges for doctors in being able to balance the need to see patients with costs, et cetera," Michtalik said. "There's not a lot of literature. We're still working on finding that right balance, an ideal model that works for patients, physicians and institutions."
Dr. Eric Howell, a physician hospitalist at Johns Hopkins Bayview Medical Center who is not affiliated with the study, said physician assistants and nurse practitioners already serve effectively in a number of capacities in hospitals.
The key, he said, is proper training.
"With all professionals, from physicians to physician assistants to anyone else working in a hospital, they need to be properly onboarded into the hospital medicine world," he said. "Hospitals have become complicated. … With the right amount of training, mentoring and onboarding, physician assistants can be effective teams members."
At Anne Arundel Medical Center, physician assistants are required to get specialized training at the hospital on top of the general education that is part of their degree, which is usually a master's from a physician assistant program. They also have as much contact with a partnering physician as they need.
There are approximately 110,000 physician assistants in the United States. Their numbers increased 36 percent from 2010 to 2015, according to the American Academy of Physician Assistants. More than half work in hospitals and more than 6 percent work primarily in a hospitalist position at least some of the time, meaning they serve in a primary care role. Many physician assistants work in more than one institution.
In Maryland, more than 11.6 percent physician assistants work in hospital medicine, which officials said could be because of "more flexible" state laws that govern such things as how many physician assistants can work with one doctor and how much autonomy they are permitted.
"We've really expanded into positions that used to have physicians in those roles," said Josanne K. Pagel, president of the academy and executive director of physician assistant services for the Cleveland Clinic Health System. "That physician assistant is your provider."
She said a physician assistant can provide consistency when many hospitals are staffed with residents, or doctors in training, who rotate in and out of departments. She said that can improve care and patient satisfaction.
On a recent day, Kelly Corcoran, a physician assistant working as a hospitalist at Anne Arundel Medical Center, walked into a patient's room and sat down next to Mary Franklin, who had just undergone a gastrointestinal procedure. Corcoran introduced herself, told Franklin what to expect going forward and asked if she had questions.
Corcoran turned to the patient's daughter and asked if she had questions. Then they spent a bit of time bonding over the fact that Franklin and Corcoran were both from Cincinnati.
"When you go to see patients, you find it's sometimes overwhelming to them because they are being seen by so many people and making life-altering decisions," Corcoran said. "I introduce myself and explain I'm their primary care provider for the inpatient world. I try to put them at ease."
Corcoran said many people have never heard of physician assistants, so she also takes time to explain her role and her plan for their care. Patients don't generally ask for a physician, though some want to know why their own primary care doctor doesn't come to the hospital to treat them.
Franklin said she wasn't bothered that a physician assistant was in charge of her care. She'd seen a couple during her hospital stay and thought they spent more time with her than a doctor normally would.
"They seem knowledgeable and they're easy to talk to," Franklin said. "I feel comfortable with them."