Examining referral practices of primary care physician assistants.

BACKGROUND: Various barriers to specialty referrals that are initiated by physician assistants (PAs) have been reported to limit a PA's ability to care for patients effectively when they have a medical problem that requires specialty intervention. To assist in evaluating this matter, we conducted a survey to assess referral practices and perceived barriers to referral among primary care PAs in the United States. METHODS: A cross-sectional, random sample of 500 primary care PAs from across the United States was surveyed to determine their referral practices and perceived barriers to referrals. Standard descriptive statistics and univariate analysis of variables were carried out using Pearson chi-squared tests. RESULTS: Seventy-one percent of respondents identified barriers to referral of patients to specialists, although 86% were satisfied with their level of autonomy. The most frequently identified barrier (38%) was the patient's insurance company. This is not an unexpected finding, considering the managed care environment in which medicine is practiced in the United States. Of respondents who mentioned this barrier, the majority were in practice 5 years or less (P < .05) and lived in a community with 10,000 or more people (P < .05). Seventeen percent of respondents also identified refusal or reluctance of specialists to accept referrals from PAs as a barrier; of respondents who mentioned this barrier, the majority had been in practice 5 or fewer years (P < .05) and worked in a community of 10,000 or more people (P < .01). A reassuring finding was that the majority of PAs (86%) were satisfied with their level of autonomy in making referrals. This may reflect the level of confidence that supervising and specialty physicians have in a PA's ability to make appropriate decisions regarding referrals. CONCLUSIONS: Further research is needed to determine whether these barriers affect a patient's access to cost-effective, high-quality care from specialist physicians.

Breaking down barriers: multidisciplinary education model.

A pilot project was implemented involving students from three disciplines: dental hygiene, physical therapy, and physician assistant. The purpose was to prepare students to work together in multidiscipline teams utilizing concepts of problem-based learning (PBL) on both simulated and real patients. The project was divided into three phases. Phase I introduced discipline specific information, team concepts, and PBL concepts. Phase II involved students working in multidisciplinary teams solving a simulated patient case in the PBL format. Phase III consisted of students working in small groups and on real patients, performing an extraoral/intraoral and periodontal examination, a problem oriented physical examination, and a neuromuscular assessment. Pre and posttest evaluation of Phase I revealed no difference in knowledge among the three disciplines. Of those students evaluating Phase II and III, 100% felt PBL was an effective means of presenting multidisciplinary material; 93% reported enhanced problem-solving; 98% indicated improvements in working in groups; and 98% felt they had learned more about each other's discipline. This model may provide a viable means to prepare interdisciplinary teams to work effectively together.

Zidovudine adherence among individuals with HIV infection.

The objective was to investigate the relationships among health beliefs, attitudes, and zidovudine compliance in individuals with HIV infection. A survey was administered to 52 individuals with HIV infection. The survey items, which reflected concerns expressed about zidovudine, were generated based on barriers to and benefits of zidovudine and the perceived susceptibility to and perceived severity of HIV as described by the health belief model (HBM). These items were expressed as attitudes and beliefs. Items were subjected to factor analysis, and survey results were correlated with laboratory data to predict adherence to their prescribed medication-taking regimen. Data indicated that 42.3% of the subjects were compliant with zidovudine. Factor analysis identified four dimensions: problems taking and scepticism about zidovudine; degree of concern about HIV; perceived severity of HIV; and physical barriers to taking zidovudine. Logistic regression analysis (forward conditional entry) identified those who were having problems taking zidovudine and who were sceptical about its effectiveness, and ethnicity as significant independent predictors of compliance, correctly classifying 75% of cases (p < 0.01). The fact that subjects who have problems taking zidovudine or are sceptical about the value of zidovudine are less compliant, and that this dimension is a significant predictor of compliance, suggests that non-compliance is related to attitudes and beliefs about zidovudine. This is consistent with the HBM, which holds that the balance between barriers and benefits of a health-related behaviour are significant determinants of outcome.

Counseling patients with HIV infection.

With the human immunodeficiency virus (HIV) still spreading rapidly throughout the nation, all health care professionals must be skilled not only in the technical aspects of management, but also in patient counseling. Patients are concerned about deteriorating health and the prospect of death, but also about treatment options and financial problems related to the disease. Clinicians who provide counseling must be familiar with these concerns as they explain the medical options to patients and help patients work through the stages of adjustment.