PHYSICIAN ASSISTANT A Guide to Clinical Practice SIXTH EDITION Ruth Ballweg, MPA, PA-C Emeritus, DFAAPA Professor Emeritus Department of Family Medicine University of Washington School of Medicine Seattle, Washington Director of International Affairs National Commission on Certification of Physician Assistants Johns Creek, Georgia Darwin Brown, MPH, PA-C, DFAAPA Physician Assistant Educator Omaha, Nebraska Daniel T. Vetrosky, PhD, PA-C, DFAAPA Associate Professor (Ret.) and Part Time Instructor University of South Alabama Department of Physician Assistant Studies Pat Capps Covey College of Allied Health Professions Mobile, Alabama Tamara S. Ritsema, MPH, MMSc, PA-C/R Assistant Professor Department of Physician Assistant Studies George Washington University School of Medicine and Health Sciences Washington, DC Adjunct Senior Lecturer Physician Assistant Programme St. George’s, University of London London, United Kingdom 1600 John F. Kennedy Blvd. Ste 1800 Philadelphia, PA 19103-2899 PHYSICIAN ASSISTANT: GUIDE TO CLINICAL PRACTICE, SIXTH EDITION ISBN: 978-0-323-40112-8 Copyright © 2018 by Elsevier, Inc. All rights reserved. Previous editions copyrighted 2013, 2008, 2003, 1999, 1994 by Saunders, an imprint of Elsevier. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluat- ing and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each prod- uct to be administered, to verify the recommended dose or formula, the method and duration of admin- istration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Library of Congress Cataloging-in-Publication Data Names: Ballweg, Ruth, editor. | Brown, Darwin, editor. | Vetrosky, Daniel T., editor. | Ritsema, Tamara S., editor. Title: Physician assistant : guide to clinical practice / [edited by] Ruth Ballweg, Darwin Brown, Daniel T. Vetrosky, Tamara S. Ritsema. Other titles: Physician assistant (Ballweg) Description: Edition: sixth. | Philadelphia, PA : Elsevier, [2017] | Includes bibliographical references and index. Identifiers: LCCN 2016053047 | ISBN 9780323401128 (pbk. : alk. paper) Subjects: | MESH: Physician Assistants | Clinical Competence | Professional Role | Delivery of Health Care--methods | United States Classification: LCC R697.P45 | NLM W 21.5 | DDC 610.7372069--dc23 LC record available at https://lccn.loc.gov/2016053047 Content Strategist: Sarah Barth Content Development Specialist: Joan Ryan Publishing Services Manager: Patricia Tannian Project Manager: Ted Rodgers Design Direction: Patrick Ferguson Printed in United States of America Last digit is the print number: 9 8 7 6 5 4 3 2 1 C ontributors David P. Asprey, PhD, BA, BS, MA Anthony Brenneman, MPAS, PA-C Professor and Program Director Director and Associate Professor Physician Assistant Program Department of Physician Assistant Studies and College of Medicine, University of Iowa Services Iowa City, Iowa Carver College of Medicine University of Iowa Ruth Ballweg, MPA, PA-C Emeritus, DFAAPA Iowa City, Iowa Professor Emeritus Darwin Brown, MPH, PA-C, DFAAPA Department Family Medicine University of Washington School of Medicine Formerly Assistant Professor Seattle, Washington University of Nebraska Medical Center Director of International Affairs Physician Assistant Program National Commission on Certification of Physician Omaha, Nebraska Assistants Michelle Buller, MMS, PA-C Johns Creek, Georgia Academic Director/Associate Professor Kate Sophia Bascombe, BSc, PGDip Physician Assistant Studies Program Teaching Fellow Union College Physician Associate Studies Lincoln, Nebraska St. George’s University of London Reamer L. Bushardt, PharmD, PA-C, DFAAPA Physician Associate General Practice Senior Associate Dean for Health Sciences Glebe Road Surgery Professor, Department of Physician Assistant Studies London, United Kingdom George Washington University School of Medicine and Health Sciences Wallace Boeve, EdD, PA-C Washington, DC Professor Robin N. Hunter Buskey, DHSc, MPAS, PA-C Program Director Physician Assistant Program Senior Physician Assistant Bethel University U.S. Department of Justice St. Paul, Minnesota Federal Bureau of Prisons Medical Center Butner, North Carolina Jonathan M. Bowser, MS, PA-C Jill Cavalet, MHS, PA-C Associate Dean of Physician Assistant Studies at the School of Medicine Clinical Associate Professor Associate Professor of Pediatrics Physician Assistant Department Program Director of the Child Health Associate Saint Francis University Physician Assistant Program Loretto, Pennsylvania University of Colorado School of Medicine Jeff W. Chambers, PA-C Denver, Colorado Physician Assistant St. Mary’s Health Care System Athens Regional Medical Center Athens, Georgia v vi Contibutors Torry Grantham Cobb, MPH, MHS, DHSc, Christine Everett, PhD, MPH, PA-C PA-C Assistant Professor Dartmouth Medical School Duke Physician Assistant Program Hanover, New Hampshire Department of Community and Family Medicine Dartmouth-Hitchcock Medical Center Duke University School of Medicine Lebanon, New Hampshire Durham, North Carolina Roy H. Constantine, PA-C, MPH, PhD Jennifer Feirstein, MSPAS, PA-C Assistant Director of Mid-Level Practitioners Clinical Coordinator and Assistant Professor St. Francis Hospital–The Heart Center Department of Physician Assistant Studies Roslyn, New York A.T. Still University Professor of Health Sciences Mesa, Arizona Trident University International Christopher P. Forest, MSHS, PA-C, DFAAPA Cypress, California Director of Research Marci Contreras, MPAS, PA-C Assistant Professor of Clinical Family Medicine Assistant Professor Keck School of Medicine Physician Assistant Studies University of Southern California University of Texas Medical Branch at Galveston Division of Physician Assistant Studies (UTMB) Primary Care Physician Assistant Program Galveston, Texas Alhambra, California Dan Crouse, MPAS, PA-C April Gardner, MSBS, PA-C Assistant Professor Assistant Professor Department of Family and Preventive Medicine Program Director and Academic Coordinator Director of Clinical Evaluation, Division of Department of Physician Assistant Studies Physician Assistant Studies University of Toledo University of Utah Toledo, Ohio Salt Lake City, Utah Constance Goldgar, MS, PA-C Ann Davis, MS, PA-C Associate Professor Vice President, Constituent Organization Outreach University of Utah Physician Assistant Program and Advocacy Salt Lake City, Utah American Academy of Physician Assistants Earl G. Greene III Alexandria, Virginia Managing Attorney Justine Strand de Oliveira, DrPH, PA-C, Law Offices of Idleman and Greene DFAAPA Omaha, Nebraska Professor Noelle Hammerbacher, MS Vice Chair for Education Department of Community and Family Medicine Freelance Examination Editor/Technical Writer Professor, Duke School of Nursing Philadelphia, Pennsylvania Affiliate Faculty, Duke Global Health Institute Virginia McCoy Hass, DNP, FNP-C, PA-C Duke University School of Medicine Durham, North Carolina Assistant Clinical Professor Former Director, Nurse Practitioner Program Sondra M. DePalma, MHS, PA-C, CLS, Former Interim Director, Physician Assistant Program DFAAPA, AACC Betty Irene Moore School of Nursing Assistant Director of Advanced Practice Family Nurse Practitioner and Physician Assistant Penn State Milton S. Hershey Medical Center Programs Physician Assistant and Clinical Lipid Specialist Sacramento, California Penn State Hershey Heart and Vascular Institute Hershey, Pennsylvania Contibutors vii Erin Hoffman, MPAS, PA-C Bri Kestler, MMS, PA-C Assistant Professor Assistant Professor Department of Physician Assistant Education Department of Physician Assistant Studies University of Nebraska Medical Center University of South Alabama Omaha, Nebraska Mobile, Alabama Trenton Honda, MMS, PA-C William C. Kohlhepp, DHSc, PA-C Director and Assistant Clinical Professor Professor of Physician Assistant Studies Physician Assistant Program Dean, School of Health Sciences Northeastern University Quinnipiac University Boston, Massachusetts Hamden, Connecticut Theresa Horvath, MPH, PA-C, DFAAPA David H. Kuhns, MPH, PA-C, CCPA, DFAAPA Program Director Consultant on International Physician Assistant Physician Assistant Institute Education University of Bridgeport Advisor to the University of Aberdeen (Scotland) Bridgeport, Connecticut Physician Assistant Program Advisor to the Royal College of Surgeons in Ireland Hannah Huffstutler, PA-C, MHS Advisor to the European Physician Assistant Assistant Professor Cooperative (EuroPAC) Physician Assistant Studies Adjunct Faculty, Arcadia University Physician University of South Alabama Assistant Program Pat Capps Covey College of Allied Health Glenside, Pennsylvania Professions Luppo Kuilman, MPA Mobile, Alabama Program Manager Emily Joy Jensen, MMSc, PA-C Master Physician Assistant Program Surgical and Inpatient Physician Assistant School of Health Care Studies Piedmont Transplant Institute Hanze University of Applied Sciences, Groningen Piedmont Atlanta Hospital The Netherlands; Atlanta, Georgia Adjunct Professor Department of Physician Assistant Studies James C. Johnson III, MPAS, PA-C College of Health and Human Services Assistant Professor Northern Arizona University Department of Physician Assistant Studies Phoenix, Arizona High Point University Barbara Coombs Lee, JD, FNP Congdon School of Health Sciences High Point, North Carolina President Compassion and Choices Gerald Kayingo, PhD, PA-C Denver, Colorado Director for the Master of Health Services-Physician Susan LeLacheur, DrPH, PA-C Assistant Program Assistant Clinical Professor Associate Professor of Physician Assistant Studies Betty Irene School of Nursing at University of School of Medicine and Health Sciences California, Davis The George Washington University Sacramento, California Washington, DC Kathy A. Kemle, MS, PA-C Jason Lesandrini, PhD(c) Assistant Professor Executive Director of Medical and Organizational Family Medicine Ethics, Wellstar Health System Mercer University Adjunct Faculty, Department of Physician Assistant Macon, Georgia Studies, Mercer University, Atlanta, Georgia Adjunct Faculty, Department of Physician Assistant Studies, Philadelphia College of Osteopathic Medicine, Suwanee, Georgia viii Contibutors Rebecca Maldonado, MSHPE, PA-C Debra S. Munsell, DHSC, PA-C, DFAAPA Associate Program Director Associate Professor Child Health Associate/Physician Assistant Program Program Director, Master of Physician Assistant University of Colorado Studies Program Denver, Colorado Louisiana State University Health Sciences Center New Orleans, Louisiana Erin Nicole Lunn McAdams, PA-C, MHS Lillian Navarro-Reynolds, MS, PA-C Assistant Professor Department of Physician Assistant Studies Assistant Professor University of South Alabama Physician Assistant Program Pat Capps Covey College of Allied Health Oregon Health Sciences University Professions Portland, Oregon Mobile, Alabama Kevin Michael O’Hara, MMSc, MS, PA-C Nancy E. McLaughlin, MHA, DHSc, PA-C Assistant Professor Assistant Professor Physician Associate Program Department of Physician Assistant Studies Yale School of Medicine Philadelphia College of Osteopathic Medicine New Haven, Connecticut Philadelphia, Pennsylvania Courtney J. Perry, PharmD Steven Meltzer, BA, BHSc, PA-C Assistant Professor Director, Outreach and Eastern Washington Department of Physician Assistant Studies Education Programs Wake Forest School of Medicine MEDEX Northwest Physician Assistant Program Winston-Salem, North Carolina University of Washington Ron W. Perry, MS, MPAS, MEd, Spokane, Washington DFAAPA, PA-C Anthony A. Miller, MEd, PA-C Program Director, Interservice Physician Assistant Professor and Director Program (IPAP) Division of Physician Assistant Studies Graduate School, Health Readiness Center of Shenandoah University Excellence Winchester, Virginia Army Medical Center & School, Joint Base San Antonio Margaret Moore-Nadler, DNP, RN San Antonio, Texas University of South Alabama Maura Polansky, MS, MHPE, PA-C College of Nursing Community Mental Health Program Director, Curriculum Development, Mobile, Alabama Department of Clinical Education Program Director, Office of Physician Assistant Dawn Morton-Rias, EdD, PA-C Education President and CEO The University of Texas MD Anderson Cancer National Commission on Certification of Physician Center Assistants Houston, Texas Johns Creek, Georgia Michael L. Powe, BS Karen Mulitalo, MPAS, PA-C Vice President, Reimbursement and Professional Associate Professor Advocacy Program Director American Academy of Physician Assistants Division of Physician Assistant Studies Alexandria, Virginia Department of Family and Preventive Medicine Brenda Quincy, PhD, MPH, PA-C University of Utah School of Medicine Salt Lake City, Utah Associate Professor College of Pharmacy and Health Sciences Butler University Indianapolis, Indiana Contibutors ix Michael Rackover, MS, PA-C Craig S. Scott, PhD Theodore C. Search Emeritus Professor Professor of Biomedical Informatics and Medical Physician Assistant Program Education Philadelphia University University of Washington School of Medicine Philadelphia, Pennsylvania Seattle, Washington Stephanie M. Radix, JD Freddi Segal-Gidan, PhD, PA-C Senior Director, Constituent Organization Outreach Assistant Clinical Professor of Neurology and and Advocacy Gerontology American Academy of Physician Assistants University of Southern California (USC) Keck Alexandria, Virginia School of Medicine Los Angeles, California Scott D. Richards, PhD, PA-C, DFAAPA Director of Rancho/USC California Alzheimer’s Founding Chair and Director Disease Center (CADC) Department of Physician Assistant Studies Rancho Los Amigos National Rehabilitation Center School of Health Sciences Downey, California Emory & Henry College Edward M. Sullivan, MS, PA-C Marion, Virginia Physician Assistant Robin Risling-de Jong, PA-C, MHS J. Kirkland Grant Obstetrics and Gynecology Practice Assistant Professor Sunnyvale, Texas Department of Physician Assistant Studies Stephane VanderMeulen, MPAS, PA-C University of South Alabama Mobile, Alabama Associate Professor Founding Program Director Tamara S. Ritsema, MPH, MMSc, PA-C Physician Assistant Program Assistant Professor Creighton University School of Medicine George Washington University School of Medicine Omaha, Nebraska and Health Sciences Daniel T. Vetrosky, PhD, PA-C, DFAAPA Washington, DC Associate Professor (Ret.) and Part Time Instructor Elizabeth Rothschild, MMSc, PA-C University of South Alabama Assistant Professor Department of Physician Assistant Studies Physician Assistant Division Pat Capps Covey College of Allied Health Department of Family and Preventive Medicine Professions Emory University School of Medicine Mobile, Alabama Atlanta, Georgia Lisa K. Walker, MPAS, PA-C Barbara Saltzman, PhD, MPH Director, Physician Assistant Studies Program Assistant Professor Massachusetts General Hospital Institute of Health Public Health and Preventive Medicine Professions University of Toledo College of Medicine and Life Boston, Massachusetts Sciences Natalie Walkup, MPAS, PA-C Toledo, Ohio Assistant Professor Patty J. Scholting, MPAS, MPH, PA-C Associate Program Director Assistant Professor Department of Physician Assistant Studies Physician Assistant Program University of Toledo University of Nebraska Medical Center Toledo, Ohio Omaha, Nebraska Jennifer B. Wall, MSPAS, PA-C Assistant Professor Department of Physician Assistant Studies The George Washington University Washington, D.C. x Contibutors Chantelle Wolpert, PhD, MBA, PA-C, GC Joseph Zaweski, MPAS, PA-C Assistant Professor and Research Coordinator Assistant Dean and Program Director Department of Physician Assistant Studies Physician Assistant Program School of Health Sciences School of Nursing and Health Professions Emory & Henry College Valparaiso University Marion, Virginia Valparaiso, Indiana Johnna K. Yealy, MSPAS, PA-C Olivia Ziegler, MS, PA Physician Assistant Program Director Assistant Chief, Academic Affairs University of Tampa Physician Assistant Education Association Tampa, Florida Washington, DC Gwen Yeo, PhD Director Emerita, Senior Ethnogeriatric Specialist Stanford Geriatric Education Center Stanford University School of Medicine Stanford, California F oreword Thirty-one years ago, doctors were in short sup- needed more components in the system. The physi- ply. Nurses were even scarcer. The old model of cian assistant (PA) was born! the doctor, a receptionist, and a laboratory tech- Nurses, laboratory technicians, and other health nician was inadequate to meet the needs of our professionals were educated in their own schools, increasingly complex society. Learning time had which were mostly hospital related. The new prac- disappeared from the schedule of the busy doc- titioner (the PA) was to be selected, educated, and tor. The only solution that the overworked doctor employed by the doctor. The PA—not being geo- could envisage was more doctors. Only a doctor graphically bound to the management system of the could do doctors’ work. The lengthy educational hospital, the clinic, or the doctor’s office—could pathway (college, medical school, internship, resi- oscillate between the office, the hospital, the operat- dency, and fellowship) must mean that only persons ing room, and the home. with a doctor’s education could carry out a doctor’s A 2-year curriculum was organized at Duke Medi- functions. cal School with the able assistance of Dr. Harvey I examined in some detail the actual practice of Estes, who eventually took the program under the medicine. After sampling the rich diet of medicine, wing of his department of Family and Community most doctors settled for a small area. If the office was Medicine. The object of the 2-year course was to set up to see patients every 10 to 15 minutes and to expose the student to the biology of human beings charge a certain fee, the practice conformed. If the and to learn how doctors rendered services. On outcome was poor, or if the doctors recognized that graduation, PAs had learned to perform many tasks the problem was too complex for this pattern of prac- previously done by licensed doctors only and could tice, the patient was referred. serve a useful role in many types of practices. They Doctors seeing patients at half-hour or 1-hour performed those tasks that they could do as well as intervals also developed practice patterns and set their doctor mentors. If the mentor was wise, the PA fee schedules to conform. The specialists tended to mastered new areas each year and increased his or treat diseases and leave the care of patients to others. her usefulness to the practice. Again, they cycled in a narrow path. Setting no ceilings and allowing the PA to grow The average doctors developed efficient patterns have made this profession useful and satisfying. of practice. They operated 95% of the time in a habit Restricting PAs to medical supervision has given mode and rarely applied a thinking cap. Because them great freedom. Ideally, they do any part of their they did everything that involved contact with the mentors’ practice that they can do as well as their patients, time for family, recreation, reading, and mentors. furthering their own education disappeared. The PA profession has certainly established itself Why this intense personalization of medical prac- and is recognized as a part of the medical system. PAs tice? All doctors starting practices ran scared. They will be assuming a larger role in the care of hospital wanted to make their services essential to the well- patients as physician residency programs decrease being of their patients. They wanted the patient to in size. As hospital house staff, PAs can improve the depend on them alone. After a few years in this mode, quality of care for patients by providing continuity they brainwashed themselves and actually believed of care. that only they could obtain information from the Because of the close association with the doctor patient and perform services that involved physical and patient and the PAs’ varied duties, PAs have an contact with the patient. intimate knowledge of the way of the medical world. During this time I was building a house with my They know patients, they are aware of the triumphs own hands. I could use a wide variety of materials and failures of medicine, and they know how doctors and techniques in my building. I reflected on how think and what they do with information collected inadequate my house would be if I were restricted to about patients. For these reasons, they are in demand only four materials. The doctor restricted to a slim by all businesses that touch the medical profession. support system could never build a practice adequate One of the first five Duke students recently earned to meet the needs of modern medicine. He or she a doctoral degree in medical ethics and is working in xi