Physician Assistants Research Articles

Addressing Burnout inthe Primary Care Setting: The Impact ofan Evidence-Based Mindfulness Toolkit.

Burnout is insidious and manifests over prolonged, repeated exposure to occupational stressors. There is a growing crisis among health care workers (HCWs) due to high levels of burnout and associated adverse outcomes. Identifying and addressing burnout can be problematic due to extensive variances of perceived occupational stressors across HCWs. Mindfulness-based training can enhance individual HCWs' abilities to perceive and constructively respond to stresses endemic in the health care environment. It can reduce the prevalence of burnout in the primary care setting. An evidence-based multimodal Mindfulness-Based Stress Reduction toolkit (MBSR TK) was designed, implemented, and evaluated for its impact on HCWs' self-reported stress levels (SRSL). A pre-post-program evaluation explored the impact of a multimodal toolkit program on HCW SRSL with the Mini-Z burnout survey (MZBS). The MBSR TK program, consisting of a 45 minute introduction and 4 biweekly 15 minute mindfulness sessions offering acupressure, meditation, journaling for gratitude, and self-compassion was designed, delivered, and evaluated with HCWs across 2 military primary care clinics in South Texas. All HCWs across 2 Air Force family practice clinics were invited to participate in all toolkit components. Seventy percent of all HCWs (N = 90) attended the introduction session. Thirty-seven (41%) HCWs completed pre and post MZBSs, and these responses are included in the data analysis section. The most represented HCWs were registered nurses, physician assistants, and technicians, respectively, at 24%, 21%, and 18%. The Wilcoxon Signed-Rank test examined changes in HCWs' SRSL after participation in the MBSR TK program. HCWs who attended the introduction plus one biweekly session showed statistically significant decreases in self-reported stress (P = 0.018) and burnout (P = 0.045) and a significant increase in electronic health record proficiency (P = 0.033). Multimodal mindfulness toolkits to address SRSL burnout are practical, accessible, easily implemented, adaptive to any environment, and can decrease burnout with participation with just one 15 minute session. This MBSR TK implementation effectively lowered self-reported stress in HCWs who are repeatedly challenged to adapt to various settings around the world during peacetime, wars, natural disasters, humanitarian crises, and now, pandemics.

Physician associates (PAs) experiencing difficulty.

Physician associates (PAs) experiencing difficulty.

Effect of Electroacupuncture Versus Cognitive Behavioral Therapy for Perimenopausal Insomnia: Protocol for a Noninferiority Randomized Controlled Trial.

Perimenopausal insomnia (PMI) has a high global incidence, which is common in middle-aged women and is more severe than nonmenopausal insomnia. Effective treatments with fewer side effects and more consistent repeatable results are needed. Acupuncture, a therapy based on traditional Chinese medicine, is safe and may be effective for PMI. It is widely accepted in Western countries, and evidence supports the use of acupuncture as a main or supplementary therapy. Cognitive behavioral therapy is also used to improve sleep quality. It has structured sessions and has been recommended as a first-line treatment for insomnia (cognitive behavioral therapy for insomnia [CBT-I]) by the American Association of Physicians. However, few randomized controlled trials have been conducted to compare the effectiveness of these 2 therapies. This study will be performed in perimenopausal women with insomnia to determine the efficacy of electroacupuncture (EA) versus CBT-I. This study aimed to compare the preliminary effectiveness and safety of EA and CBT-I for PMI through a randomized controlled noninferiority study design. This study is designed as an assessor-blinded, noninferiority, randomized controlled trial. A total of 160 eligible participants with PMI will be randomly divided into 2 groups to receive either EA or CBT-I. Participants in the EA group will receive electroacupuncture for 8 weeks. The intervention will be delivered 3 times weekly for a total of 12 sessions and 2 times weekly for the next 4 weeks. Meanwhile, participants in the control group will undergo CBT-I (once a week) for 8 weeks. Treatment will use 7 main acupoints (GV20, DU24, EX-HN3, EX-HN18, EX-CA1, RN6, and RN4) and an extra 4 acupoints based on syndrome differentiation. The primary outcome is the Insomnia Severity Index. The secondary outcome measures are the Pittsburgh Sleep Quality Index; Menopause-Specific Quality of Life; Menopause Rating Scale; Hamilton Depression Scale; Hamilton Anxiety Scale; hot flash score; and the level of estradiol, follicle-stimulating hormone, and luteinizing hormone in serum. Sleep architecture will be assessed using polysomnograms. Participants are currently being recruited. The first participant was enrolled in January 2023, marking the initiation of the recruitment phase. The recruitment process is expected to continue until January 2025, at which point data collection will commence. This trial represents a pioneering effort to investigate the efficacy and safety of EA and CBT-I as interventions for PMI. It is noteworthy that this study is conducted solely within a single center and involves Chinese participants, which is a limitation. Nonetheless, the findings of this study are expected to contribute valuable insights for clinicians engaged in the management of PMI. Chinese Clinical Trial Registry ChiCTR2300070981; https://www.chictr.org.cn/showprojEN.html?proj=194561. DERR1-10.2196/51767.

PA Scholars: What Drives and Inhibits Success?

The full expression of an educator includes scholarship, yet many physician assistant (PA) educators are not published. Several barriers unique to PA education are often cited to explain this phenomenon. However, some in the PA profession have become prolific writers despite working in the same environment. In this study, authors strove to understand what motivated these productive faculty by posing 2 research questions: (1) What are the drivers of success for high-performing PA scholars and (2) how do high performing PA scholars overcome barriers? A qualitative study using a constructivist, grounded theory approach explored the experiences and motivation of PA-credentialed educators who published >5 peer-reviewed articles and whose body of work achieved an h -index of >3. High-performing scholars valued scholarship as a creative outlet and a rewarding pursuit. Scholars achieved a sense of fulfillment in their work. Research and writing were described as protective against burnout. Participants viewed barriers differently than other educators. Barriers were acknowledged, but participants developed strategies to overcome obstacles. Mentorship was seen as crucial to success. A nuanced understanding of PA research and the characteristics associated with high-performing PA scholars emerged. The study identified developmental stages associated with the formation of a scholar. Progression from prescholar to mature scholar has important implications for initiatives designed to increase scholarship and provides evidence to support the claim that scholarship positively affects job satisfaction, personal well-being, and talent retention.

Transferring people with dementia to severe challenging behavior specialized units, an in-depth exploration

Objectives One of the main reasons for people with dementia to move to a dementia special care unit of a nursing home is challenging behavior. This behavior is often difficult to manage, and in the Netherlands, residents are sometimes relocated to a severe challenging behavior specialized unit. However, relocation often comes with trauma and should be prevented if possible. This study aimed to investigate the patient- and context-related reasons for these relocations. Methods Qualitative multiple case study using individual (n = 15) and focus group interviews (n = 4 with n = 20 participants) were held with elderly care physicians, physician assistants, psychologists, nursing staff members, and relatives involved with people with dementia and severe challenging behavior who had been transferred to a severe challenging behavior specialized unit. Audio recordings were transcribed and analyzed with thematic analysis, including directed content analysis. Results After five cases, data-saturation occurred. The thematic analysis identified three main processes: increasing severity of challenging behavior, increasing realization that the clients’ needs cannot be met, and an increasing burden of nursing staff. The interaction between these processes, triggered mainly by a life-threatening situation, led to nursing staff reaching their limits, resulting in relocation of the client. Conclusion Our study resulted in a conceptual framework providing insight into reasons for relocation in cases of severe challenging behavior. To prevent relocation, the increasing severity of challenging behavior, increasing burden on nursing staff, and increasing realization that the clients’ needs cannot be met need attention.

Abstract 14574: Trends in the Utilization of Sacubitril/Valsartan by Cardiologists: A Safety-Net Hospital Experience

Background: Sacubitril/Valsartan has gained significant momentum regarding management of heart failure. In the latest 2022 HF guideline, Sacubitril/Valsartan is recommended as a first-line treatment and to replace well-tolerated ACEi/ARB’s. We decided to evaluate current utilization trends with regards to prescription of Sacubitril/Valsartan at our safety-net hospital. Methods: For this retrospective study,a chart review identified Sacubitril/Valsartan use in a total of 769 patients,which was catalogued by drug dose, division use, and prescriber specialty at University Health Truman Medical Center in Kansas City, Missouri from October 1, 2021 thru October 31, 2022. Results: Of the 769 patients prescribed Sacubitril/Valsartan, 497 patients were prescribed the 24 mg/26 mg dose, 193 patients were on 49 mg/51 mg dose, and 79 patients were provided a 97 mg/103 mg dose (Figure 1). Cardiologists were only involved in 23% of all Sacubitril/Valsartan prescriptions while ancillary staff providers including nurse practitioners, physician assistants and pharmacists representing the predominant number of healthcare professionals (50%) prescribing Sacubitril/Valsartan (Figure 2). Conclusion: Despite the robust evidence supporting the benefit of using Sacubitril/Valsartan in HF and the unique opportunity that Cardiologists have in taking ownership in optimizing HF management; our data seems to suggest that prescription rates of Sacubitril/Valsartan by Cardiologists at our institution remains low when compared to other specialties. This may contribute to an undertreatment of high-risk HF patients.

Management ofCombat Casualties during Aeromedical Evacuation from a Role 2 to a Role 3 Medical Facility.

Emergent clinical care and patient movements through the military evacuation system improves survival. Patient management differs when transporting from the point-of-injury (POI) to the first medical treatment facility (MTF) versus transporting from the Role 2 to the Role 3 MTF secondary to care rendered within the MTF, including surgery and advanced resuscitation. The objective of this study was to describe care provided to patients during theater inter-facility transports and compare with pre-hospital transports (POI to first MTF). We performed a retrospective chart review of patients with the Role 2 to the Role 3 transports in Afghanistan and Iraq from 2007 to 2016. Data collected included procedures and events at the MTF and during transport. We compared the intra-theater transport data (Role 2 to Role 3) to data from a previous study evaluating pre-hospiital transports (POI to first MTF). We reviewed the records of 869 Role 2 to Role 3 transport patients. Role 2 to Role 3 transports were longer in duration compared to POI transports (39 minutes vs. 23 minutes) and were more likely to be staffed by advanced personnel (nurses, physician assistants, and physicians) (57% vs. 3%). The sample primarily consisted of military-aged males (mean age 27 years) who suffered from explosive or blunt force injuries. Procedures performed during each phase of care reflected the capabilities of the teams and locations. Pain and cardiac events were more common in POI evacuations compared to the Role 2 to Role 3 transports, but documentation of respiratory events, hemodynamic events, neurologic events, and equipment failure was more common during the Role 2 to Role 3 transports. Survival rates were slightly higher among the Role 2 to Role 3 cohort (98% vs. 95%, difference 3% [95% confidence interval of the difference 1-5%]). Inter-facility transports (Role 2 to Role 3) are longer in duration, transport more complex patients, and are staffed by more advanced level provider types compared to transports from POI.

Advancing primary care: Doctoral program for physician associates and nurse practitioners

The United States faces an impending crisis in primary care physician shortages, while Physician Associates (PAs) and Nurse Practitioners (NPs) are poised to help bridge the gap. This manuscript explores a groundbreaking solution: introducing a clinical doctorate program tailored to PAs and NPs, designed to equip them with the knowledge and skills to assume leadership roles in primary care. Unlike traditional medical education, this innovative approach allows these professionals to continue their clinical practice while advancing their education, addressing the workforce shortage and the need for advanced leadership within the primary care landscape. This comprehensive curriculum includes intensive didactic coursework, residency-like training, credentialing examinations, and research opportunities, positioning PAs and NPs as critical contributors to the future of primary care. By recognizing their untapped potential and investing in their advanced education, we can elevate the quality and accessibility of primary care, ensuring that healthcare delivery reaches new heights.

A Framework for Strategic Development and Integration of the Advanced Practice Executive

Health care organizations have immense opportunities to transform enterprise performance through strategic development and integration of advanced practice providers (APPs). The projected growth rate for APPs, which include advanced practice registered nurses (APRNs) and physician assistants, is 45% and 31%, respectively. This projection is based on the shortfall of physicians and the increased need to provide cost-effective care. Successful integration of APPs requires organizations to invest in the infrastructure to support this rapidly growing profession. Many health care organizations are preparing by creating a system advanced practice executive role to oversee the organizational design systemness, workforce strategy and optimization, and care design and innovation. This paper results from system advanced practice executives collaborating to define a system-level APP leader's role and responsibilities and the value brought to the health system.

The current status of diversity among physician assistants in surgery: A systematic review

Abstract It is difficult to achieve diverse representation within surgical settings, including within the ranks of physician assistants (PAs) despite research indicating that diversity improves patient outcomes and experience and benefits the workplace. The aim of this systematic review was to evaluate interventions used to support diversity among surgical PAs. Databases including PubMed (MEDLINE), Web of Science, SCOPUS, CINAHL, and Cochrane Database of Systematic Reviews were searched for publications that described interventions for increasing underrepresented in medicine and gender diversity among surgical PAs. While 20 studies were identified, none met the inclusion criteria. The absence of literature on surgical PAs led to an exploration of research conducted among surgeons, nonsurgical PAs, and PA students. While not directly applicable, results from these studies offered valuable insights into factors that impact diversity as well as strategies that foster diversity. Factors such as gender bias, discrimination, and harassment may contribute to lower numbers of underrepresented groups working in surgery. Efforts to support increased diversity include recruitment, leadership support, and mentorship programs. This systematic review highlights the need for further research to foster diversity among PAs working in surgery. While existing surgical literature offers some contextual insights, future studies on and increased attention toward this topic will improve inclusivity and create a more equitable healthcare system.

Procedures by Physician Associates in Obstetrics and Gynecology.

The number of obstetricians and gynecologists in the United States is decreasing and providers backfilling this service have not been well described. The intent of the study was to identify the skills that physician associates (PAs) in obstetrics and gynecology (OBGyn) contribute to this aspect of medicine and surgery. A survey of PAs specializing in OBGyn was conducted in 2022. The intent was to list office-based procedures that were part of their skill set. A vetted questionnaire was sent to the 1,630 American Academy of Physician Associates members who identified themselves in OBGyn at some point in their career, and 729 responded (44.7% relative risk). Most PAs (88.7%) in OBGyn first assist in surgery. This first-assist role ranged across the open, laparoscopic, and robotic-type operations. Categories of surgery included Cesarean section, hysterectomy, salpingo-oophorectomy, and subspecialty surgeries such as oncology and urogynecology. In the outpatient setting, PAs listed over 40 procedures ranging from biopsies of the endometrium, cervix, vagina, and vulva, as well as fetal assessment, ultrasonography, and long-acting contraceptive insertion and removals. The proceduralist role of PAs in OBGyn is broad. Furthermore, this role may need to be utilized more at a time of growing scarcity of clinicians. The OBGyn role for PAs adds to their specialization and increasing presence in American medicine.

Burnout among palliative care providers.

Burnout among health care professionals contributes to high job turnover. Within the United States, burnout among specialty palliative care (PC) providers will accentuate provider shortage problems. This systematic review was conducted to answer the question "what is known about burnout among specialty PC providers practicing in the United States?" More specifically, it was designed to identify the rate of burnout and factors that influence or mitigate it among PC nurse practitioners (NPs), physician assistants (PA), and physicians and to inform future research. An electronic literature search of studies conducted in the United States between 2012 and September 2022 was completed in Embase, PubMed, CINAHL, and PsycINFO. Analysis of 14 studies showed that there are five primary themes related to burnout among PC providers: (1) the rate of burnout, (2) the physical, psychological, and clinical manifestations of burnout, (3) predictors of burnout, (4) factors of resiliency, and (5) interventions piloted to decrease burnout. The majority of studies have delineated the physician role but have failed to determine the rate and factors of burnout among PC NPs and PAs. As NPs and PAs are integral to the PC provider workforce, future research should be designed to understand more clearly how burnout affects these two PC roles to inform efforts to sustain the PC workforce.

Operative or Nonoperative Treatment is Predicted Accurately for Patients Who Have Hip Complaints Consulting an Orthopedic Surgeon Using Machine Learning Algorithms Trained With Prehospital Acquired History-Taking Data

BackgroundIncreasing numbers of patients suffering from hip osteoartritis will lead to increased orthopaedic health care consumption. Artificial intelligence might alleviate this problem, using Machine learning (ML) to optimize orthopaedic consultation workflow by predicting treatment strategy (non-operative or operative) prior to consultation. The purpose of this study was to assess ML accuracy in clinical practice, by comparing ML predictions to the outcome of clinical consultations. MethodsIn this prospective clinical cohort study, adult patients referred for hip complaints between January 20th to February 20th 2023 were included. Patients completed a computer-assisted history taking (CAHT) form and using these CAHT answers, a ML-algorithm predicted non-operative or operative treatment outcome prior to in-hospital consultation. During consultation, orthopaedic surgeons and physician assistants were blinded to the prediction in 90 and unblinded in 29 cases. Consultation outcome (non-operative or operative) was compared to ML treatment prediction for all cases, and for blinded and unblinded conditions separately. Analysis was done on 119 consultations. ResultsOverall treatment strategy prediction was correct in 101 cases (accuracy 85%, P < .0001). Non-operative treatment prediction (n = 71) was 97% correct versus 67% for operative treatment prediction (n = 48). Results from unblinded consultations (86.2% correct predictions,) were not statistically different from blinded consultations (84.4% correct, P > .05). ConclusionsMachine Learning algorithms can predict non-operative or operative treatment for patients with hip complaints with high accuracy. This could facilitate scheduling of non-operative patients with physician assistants, and operative patients with orthopaedic surgeons including direct access to pre-operative screening, thereby optimizing usage of health care resources.

Clinical Utility of the 31-Gene Expression Profile Test on the Management of Cutaneous Melanoma by Nurse Practitioners and Physician Assistants.

The 31-gene expression profile (31-GEP) can predict the risk of recurrence and metastasis in cutaneous melanoma (CM). We assessed the viewpoints and use of 31-GEP testing by physician assistants (PAs) and nurse practitioners (NPs) for patients with CM. NPs and PAs (n = 369) completed an 18-question online survey about their viewpoints and use of the 31-GEP risk-stratification test. Most practitioners (n = 334, 90.5%) felt prognostic testing improved patient care and would recommend the 31-GEP to a colleague (n = 333, 90.2%) or a friend or family member (n = 289, 78.3%) who was diagnosed with CM. The 31-GEP test was used by 176 respondents in the preceding 12 months (53%). Among users of the 31-GEP test, 78% stated that the results would impact follow-up schedule and referral, 66% overall treatment decisions, 62% sentinel lymph node biopsy recommendations, and 50% surveillance imaging. In thin tumors (≤ 1 mm), 82% of 31-GEP users and 44% of nonusers stated that the 31-GEP results would impact their treatment plan decisions. The 31-GEP test significantly impacts treatment plans in CM, particularly for thin and stage I melanomas. Importantly, even nonusers stated that 31-GEP test results would impact treatment plans as well as recommendations to a friend or family member.

Evaluation of an Advanced Practice Provider Onboarding and Development Program.

To evaluate the impact of implementing a comprehensive secondary onboarding and development program within a hospital medicine group at a large tertiary academic medical institution. This was a mixed-methods study with physician and advanced practice providers (APPs) at an academic medical institution. For quantitative methods, improvement in competencies was determined using a pre-and posttest for APPs and pre- and postevaluation scores from collaborating physicians. APPs also participated in a pre- and post-self-assessment. For qualitative methods, experiences in the secondary onbo.arding and development program were assessed using semistructured interviews. For quantitative results, there were a total of 25 APPs who completed the pre- and posttest and were evaluated by at least 9 physicians. The average pretest score for APPs was 71.7% and the average posttest score was 83.0%. The average score for physicians' evaluations of APPs was 4.24/5 and increased to 4.38/5 in the postprogram evaluations. The average score for APP self-assessment pretraining was 3.52/5 and after the 12-month onboarding training, average scores increased to 3.84/5. For qualitative results, 4 APPs and 6 physicians were interviewed. Three of the APPs reported having more confidence in treating patients, whereas 1 APP viewed the program as a refresher course. All of the APPs mentioned that they would recommend the program to other APPs. Physicians reported that the program was beneficial in standardizing the care provided among the different types of APPs (physician assistants and nurse practitioners). All of the physicians also would recommend the program to other physicians and APPs.

Midwifery and APRN Scope of Practice in Abortion Care in the Early Post-Roe Era: Everything Old Is New Again.

Over the past 10 years, there has been a rapid expansion of legal and legislative changes in abortion care provision for advanced practice clinicians (APCs), including nurse practitioners, midwives, and physician associates (formerly physician assistants), with most of that expansion occurring in the last several years. This expansion has occurred via several routes (eg, legislative, popular vote, court decision, attorney general opinion), and the patchwork of legal statuses nationally creates confusion for clinicians who are unclear on current regulations. This review explores the historical context of abortion practice for APCs, as well as the primary philosophical and legal concepts relevant to this role development. Since 2012, the number of states permitting abortion practice by APCs has more than quintupled, and the changes to abortion law in the United States in the wake of the 2022 Supreme Court decision in the case of Dobbs v. Jackson Women's Center creates a new imperative to understand the role of APCs in accessing abortion care. Additionally, although the research on abortion safety for APC abortion providers is well-established, the physician-centered paradigm of abortion care has limited the ability of APCs to develop expertise in this essential public and clinical health service.

Necrotizing Soft-Tissue Infections: A Case-Based Review.

To review the assessment and management of necrotizing fasciitis. This continuing-education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. After participating in this educational activity, the participant will:1. Identify the etiologic pathogens for necrotizing fasciitis.2. Summarize assessment guidelines for patients who present with signs of necrotizing fasciitis.3. Explain recommended treatment protocols for patients who have necrotizing fasciitis.

Association Between Facility and Clinician Characteristics and Family Planning Services Provided During U.S. Outpatient Care Visits.

Recent guidelines from the Centers for Disease Control and Prevention emphasize the importance of access to comprehensive family planning services and recommend patient-centered contraceptive counseling be incorporated into routine primary care visits for reproductive-age individuals. This study aims to describe family planning service provision in outpatient care settings and assess differences by facility and clinician characteristics. Using National Ambulatory Medical Care Survey data, a nationally representative survey of outpatient care visits, we assessed family planning service provision by facility location, facility type, physician specialty, types of clinicians seen, and whether the patient was seen by their primary care provider. We used random intercept logistic regression with robust standard errors, adjusting for patient characteristics, and state and year fixed effects. The analytic sample included 53,489 patient visits with reproductive-age (15-49years) individuals between 2011 and 2019. Family planning services were provided at 8% of total sampled visits and were more likely to be provided in urban compared with rural areas (adjusted odds ratio, 1.45; p=.02) and at community health centers compared with private physician practices (adjusted odds ratio, 1.74; p=.00). Family planning services were also more likely to be provided when the patient saw a physician assistant or nurse compared with only a physician. After controlling for observed covariates, measures of between-clinician heterogeneity indicate wide variation in which clinicians provided family planning services. Family planning services were more likely to be provided in urban areas, at community health centers, and when patients received team-based care. The wide variation between clinicians suggests a need to better incorporate family planning services into primary care and other outpatient settings to meet patient needs and preferences.

APSHO Oncology/Hematology Advanced Practitioner Compensation Survey

The Advanced Practitioner Society for Hematology and Oncology (APSHO) launched its first oncology and hematology advanced practitioner (AP) compensation survey in 2022. This 74-question survey surveyed nurse practitioners, pharmacists, physician assistants, clinical nurse specialists, and advanced practice nurses in oncology, investigating all aspects of compensation structure, including salary, on-call payments, incentive structures where applicable, and consulting rates to work with industry partners. Data also include a concerning rate of AP burnout and intent to alter current work status by leaving the practice, leaving the specialty, reducing work hours, or leaving health care all together. Results from this survey may be beneficial in the recruitment, retention, and promotion of the AP in hematology and oncology.

Advanced Practice Providers in Departments of Family Medicine: Status, Supervision, and Services.

Nurse practitioners (NP), physician assistants (PA), and other advanced practice providers (APP) are one solution to meet health care workforce shortage. Our study examined clinical workforce decisions and perceptions of APPs and family physicians (FPs) from the perspective of a national survey chairs of Departments of Family Medicine. A survey was developed and distributed to family medicine department chairs as identified by the Association of Departments of Family Medicine (ADFM). In addition to demographic information, respondents were asked if their department directly employs APPs, major factors influencing departments of family medicine to hire APPs, services to patients currently being provided by APPs, and services preferentially provided by APPs. Descriptive statistics were reviewed. Bivariate analyses and Chi-square were computed comparing perceptions of APPs and FPs by how these types of health care providers are currently used in the respondent's clinical operation. The overall response rate for the survey was 48.4% (109/225). Most departments of family medicine (62.4%) use APPs. Access to care and filing gaps in team-based care are the primary factors for APP employment. Although most departments have APPs provide services that include complex chronic conditions complicated by coexisting conditions or not yet controlled, most department chairs do not prefer APPs provide these services. The role APPs in terms of specific patient care activities and services in the health care team of departments of family medicine is often in conflict with preferred roles as delineated by the chair.