Duke researchers lead groundbreaking studies on physician assistants

Wednesday, February 25, 2015
Morgan, Humeniuk, and Everett

Tucked into a quiet hallway of the Duke Physician Assistant Program building near downtown Durham, N.C., is a group of women working on groundbreaking research that has the potential to impact physician assistant education and the types of roles that are being created for PAs in the workforce.

These women—Perri Morgan, Ph.D., PA-C; Christine Everett, Ph.D., MPH, PA-C; and Katherine Humeniuk, MPH—sift through information made available to them via publicly available data sets, electronic health record data and insurance claims data, but also are creating infrastructure to gather their own data and support more research in the physician assistant field.

“My research focus is to understand how we can design health care teams,” says Everett, assistant professor of Community and Family Medicine. “This means defining and evaluating the roles of different professions that are on those teams as well as understanding how they work together. Really to find a sustainable approach that results in the best outcomes for patients.”

Morgan, director of research at the Duke Physician Assistant Program and associate professor of Community and Family Medicine, says that research on physician assistants is a relatively new field.

“Most fields that we’re familiar with in health care have a research training track and their graduates are prepared to do research,” Morgan says. “For example, you can get a Ph.D. in nursing and that’s research oriented. The PA clinical degree is a terminal degree, so there’s no such thing as a Ph.D. in physician assistant studies. So in the past, there have been very few PAs prepared to do research.”

Morgan says that because PAs have become a large enough part of the workforce, and because ofpredicted provider shortfalls, research on PAs is becoming more interesting to others.

That interest has created numerous collaboration opportunities for the Duke PA research group, including a collaboration between Morgan and the U.S. Department of Veteran Affairs to study the roles and outcomes of nurse practitioners and physician assistants working in VA primary care. Morgan says the PA research group took the idea to the VA primary investigator who then worked with them to create a proposal.

The award amount—$902,505—is one of the largest grants ever awarded to study PAs in primary care, according to Rod Hooker, Ph.D., MBA, PA, a retired professor of health policy who has researched the medical workforce for more than three decades.

“It’s really big news,” Hooker says. “The award recognizes the capability of Dr. Morgan as a solid and contemporary health services researcher and social scientist.”

The project has been funded for three years and will adapt methodology created by Everett for her article, “Physician Assistants and Nurse Practitioners Perform Effective Roles on Teams Caring for Medicare Patients with Diabetes.” The Physician Assistant Education Association (PAEA) awarded Everett the 2014 Article of the Year for that work.

Changing the course of PA research

The physician assistant profession is still very young, with its beginnings at Duke University 50 years ago. Dr. Eugene A. Stead, Jr., then chairman of the Department of Medicine at Duke University Medical Center, founded the Duke Physician Assistant Program and the profession in 1965. The program will celebrate 50 years of PA education at Duke in October.

Hooker, who is co-author of Physician Assistants: Policy & Practice, says that for the first quarter century of the profession, almost all research done on PAs was by non-PAs. But he says the tide has slowly shifted.

“In 2014 there were 188 papers published on some aspect of PAs,” Hooker says. “And of that 188 about 40 percent were authored by PAs. I think that’s been a substantial shift.”

Both Morgan and Everett went outside of the PA world to get doctorates in health services research at the University of Wisconsin-Madison. Morgan points out that there are others who have done that, but not many. And Morgan says many researchers have gotten doctorates in education to do education research, but that’s not what the PA research group does.

“We do health services research. So there needs to be a way to support that kind of research, and that’s what Justine {Strand de Oliveira} and Pat {Dieter} have created here.” Morgan says.

Justine Strand de Oliveira, DrPH, PA-C, FAAFP, professor and vice chair for education for Duke Community and Family Medicine, founded the research group in 2004 when she was division chief of the PA program. And Pat Dieter, MPA, PA-C, is current division chief of the Duke Physician Assistant Program and oversees the research group. Both Strand de Oliveira and Dieter collaborate with Morgan, Everett and Humeniuk on research projects.

Strand de Oliveira says she wanted to begin the research group because she saw a need for PAs to be researching their own profession.

“There was such an absence of health services research about PAs,” Strand de Oliveira says. “We as a profession have always been concerned with just getting in the trenches and delivering care, and we haven’t thought about research.”

“The idea was just to try to learn more,” Strand de Oliveira says. “There were certain things that we thought about PAs—we believed that PAs had great bedside manner that was really appreciated by patients in general—but there was no evidence of that. We thought that we were cost-effective. But we didn’t have that much evidence.”

Humeniuk, Everett, and Morgan discussing research

Creating a dream team

In 2004, Strand de Oliveira recruited Morgan for a one-year research fellowship. Morgan had been teaching at the University of Wisconsin-Madison Physician Assistant Program for 10 years and had planned to return to Wisconsin after her fellowship ended, but was recruited to a faculty position at Duke and named director of research of the Duke Physician Assistant Program, a post that she has held since 2005.

Everett, who had been teaching at the University of Wisconsin-Madison PA Program and serving as their director of research, was recruited by Strand de Oliveira and Dieter in 2013 to join the Duke PA Program.

“She was being absolutely wooed by all kinds of programs,” Strand de Oliveira says. “She just had so many strengths. Her methodology is really strong. She had years where she worked at the FDA; she has a health policy background. She’s just smart as a whip.”

The team then became complete in July with the addition of Humeniuk, a research analyst, who worked with Mayo Clinic’s biomedical ethics group before joining Duke. Humeniuk works with data analysis, database building, survey development, grant editing and literature reviews.

Everett says that Duke’s PA Program is unique to have three people doing research.

“Part of it is just the dedicated resources to it that allow us to do this, but also the synergy of all three of our minds going here,” Everett says. “It takes a shop. One person alone who’s also teaching a lot and doing admissions … you can’t do big projects. So now we’re finally able to.”

Hooker says there have been many starts and stops of research divisions within PA programs, but only a handful of programs have been able to successfully maintain a research division within a PA program. He says that the Duke Physician Assistant Program is prestigious because of the number of PAs who have authored important research in sociology, history, economics and health services research.

Hooker says that Duke’s research group is in the top tier of academic PA research groups in the country. He says that the group’s core team—Morgan, Everett and Humeniuk—is a machine that takes on complex research questions and draws on scholars around the country.

“This is a trifecta of solid first-class workforce scholars that are really setting the stage, setting a very high mark, for quality research,” Hooker says. “I’m very, very impressed by their capability and their products.”

Supporting the future of PA research

Dieter says she is incredibly proud of the work the research group is doing at the Duke PA Program, particularly with the creation of an education database, which will track Duke PA students long-term—beginning with their admission, throughout their time in the program, then throughout their career.

“This is a model for collecting data about PAs that we think will be picked up through the country,” Dieter says. “And through using that data we can tell what PAs are truly using from their education.”

Morgan says that the database will allow answers to long-term questions, such as what kinds of students do the best work as PAs later.

“We’ll be able to hopefully link the students, the graduates, through some of the medical record data and insurance claims data that’s becoming more and more available so that we can look at educational outcomes,” Morgan says. “That’s always been a dream of education research.”

Morgan says the database will support research at Duke’s PA Program, but will also allow collaboration with others. Everett says they’re trying to build infrastructure to do more research and have data and infrastructure available to help other PAs and PA faculty get into research.

“We presented this at the national (PAEA) meeting and a lot of other programs want to build a similar database,” Morgan says. “We have the long-term dream of being able to pool our data with theirs, and they pool theirs with us, ideally, and be able to do multi-institutional long-term research on educational outcomes for PAs.”

“This has never been done before, so the possibilities are really huge and we’re quite proud of that,” Morgan says.


PA Research Group Peer-Reviewed Publications

2014

2013

  • Everett CM, Thorpe C, Carayon P, Palta M, Gilchrist V, Smith MA. Division of primary care services between physicians, physician assistants, and nurse practitioners for older patients with diabetes. Medical Care Research and Review 2013. 70 (5): 531-541,http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3902998/
  • Everett CM, Thorpe C, Carayon P, Palta M, Bartels C, Smith MA. Physician assistant and nurse practitioners perform effective roles on teams caring for Medicare patients with diabetes. Health Affairs 2013. 32 (11): 1942-1948, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3909681/

2012

  • Morgan P, Abbott DH, McNeill RB, Fisher DA. Characteristics of Primary Care Office Visits to Nurse Practitioners, Physician Assistants, and Physicians in United States Veterans Health Administration Facilities, 2006-2010: a retrospective cross-sectional analysis. Human Resources for Health 2012, 10(42). http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3541159/

2011

  • Morgan PA, Strand J, Short N. Physician Assistants and Nurse Practitioners: a missing component in state workforce assessments. Journal of Interprofessional Care. 2011; 25(4): 252-257,http://informahealthcare.com/doi/abs/10.3109/13561820.2010.501917
  • Alexander SC, Pollak KI, Morgan PA, Strand J, Abernethy AP, Jeffreys AS, Arnold RM, Olsen M, Rodriguez KL, Garrigues SK, Manusov JRE, Tulsky JA. How do non-physician clinicians respond to advance cancer patients’ negative expressions of emotions? Supportive Care in Cancer,2011;19:155-9, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3377476/

2010

2008

2007


Correction: The original story incorrectly stated that the project with the VA was the largest grant ever awarded to a PA investigator. The project is one of the largest grants ever awarded to study PAs in primary care.