Everyone has those moments in their life when they question the career path they have chosen.

As much as I have adored my career in invasive cardiology, even I have doubted my path at times. I believe the doubt comes from the nature of the work (the long hours, the missed lunches and late-night calls) and seldom from the environment, despite the chaotic schedule. I have been blessed with supportive work environments that have allowed me to pursue development outside of the hospital walls. If you are in a similar situation, consider making the most of your diverse work experience and continue to develop your career by becoming a Physician Assistant (PA).

Lifelong Learning

In 13 years, I have made several geographical moves in search of the ideal place to work, live and play. Regardless of where I was, the unwavering desire to expand my horizons drove my passion to seek further education. As a result, I have taken evening and weekend college courses to continually improve myself as a person and as a professional. Recently, my journey has taken me back to school full-time to become a PA. The decision to return to formal education was a difficult one and a move that was not without its difficulties in transitioning back to college life. However, I have felt it to be a natural progression from my cardiovascular knowledge and experience to pursue the PA profession.

Each program has its particular prerequisite requirements, but many programs require at least two years of college and some work experience or “shadowing” time in the healthcare field. Common prerequisite courses include biology (genetics and molecular/microbiology), anatomy, physiology, chemistry, mathematics, psychology, statistics and English. Most applicants to PA educational programs already have a Bachelor’s degree. Similar to the RCIS credential, which unites several disciplines for a common credential, the PA profession accepts students from varied backgrounds to learn a common curriculum. The professional phases of PA programs are typically two years in length after a competitive admission process. The American Academy of Physician Assistants reports that in 2007, 136 programs for PAs were accredited or provisionally accredited. Of these programs, more than 90 offered the option of a Master’s degree.1 The PA profession has been moving toward requiring Master’s degrees for new practitioners, as an increasing number of states require it for licensure. According to a 2003 census, 53% of the newly-graduated PA respondents hold a Master’s degree.2

Burden of Education

Academics are only one hardship to be considered for those who wish to transition into PA school. Finding the time to dedicate to full-time schooling is a significant burden. In my experience, I was accustomed to evenings and weekends off when I was not on call. It was my time to relax and spend time with family. Specifically, during the didactic year of the professional phase of the PA program, many luxuries of free time will be lost due to the academic demands of learning medicine.
The financial burden becomes a hurdle beyond financing the tuition for the school itself. Since you will no longer be able to work full time, your annual income will be a small fraction of the budgeted amount you relied upon working in the catheterization laboratory.

I was lucky to find a PA program within the same town where I was working — Williamsport, Pennsylvania. I accepted and maintained a per-diem status with the catheterization laboratory. There were so many times I felt overwhelmed from the demands of school that I couldn’t even consider working. However, when I had time to take call or a random shift, my fellow staff members at Williamsport Hospital stood by my decision and would allow me to earn some extra income. Though mostly limited to weekend work, the income was appreciated and certainly better than nothing. Maintaining a balance of education, free time and financial means is extremely important.

Physician Assistants in Cardiology

The time I have spent working in interventional cardiac catheterization laboratories has provided valuable experience. The patient care experience has been an advantage to me in dealing with people, learning how to listen to patients’ concerns and educating the patient on care plans. In the future I hope to utilize this experience, as certified PAs are being employed by cardiovascular departments to perform office visits, noninvasive stress testing and, less commonly, diagnostic cardiac catheterizations.

Typical inpatient duties include writing preprocedure, postprocedure and progress notes, as well as discharge orders. Less obvious tasks include providing important patient education, counseling for risk-factor management and lifestyle modifications. With their pharmacologic background, PAs are able to promptly and appropriately treat inpatients who have cardiovascular or respiratory conditions. Since they can perform rounds on inpatients, PAs afford specialty physicians more time on complex cases, and act as a vital communication liaison between patients, families and physicians.3

As the scope of practice expands for the PA profession, research data, along with ongoing quality assurance, will be crucial to document the safety and effectiveness of PAs performing invasive procedures. In 2002, a prospective study was completed following nine PAs who performed invasive procedures such as central venous catheter placement, Swan-Ganz insertions, thoracenteses, endotracheal intubations and chest tube placements in the pulmonary critical care and cardiothoracic surgery settings. The single pneumothorax complication observed in this study demonstrated that PAs can perform invasive medical procedures with a complication rate comparable to that of physicians if the PAs are given the appropriate training and oversight.4 Similarly, PAs working in cardiac catheterization and radiology departments can perform invasive procedures with similar outcomes, given the proper training.

Mr. Ricardo C. Calla, PA-C, of Central Pennsylvania Pulmonary Associates, Enola, Pennsylvania, has routinely performed right-heart catheterizations for four years and will complete over 150 procedures this year. Mr. Calla was able to perform these procedures after a standard number of procedures were staged with direct supervision. According to Mr. Calla, the limiting factor for doing such procedures is the confidence of the supervising physician and the facility regulations, not state regulations.5 Mr. Calla goes on to explain that the Pennsylvania state law is liberal concerning the performance of procedures, and these regulations differ from state to state.

A study presented at the 2001 Annual Scientific Sessions of the American College of Cardiology confirmed that PAs can perform diagnostic right- and left-heart cardiac catheterizations with coronary angiography with complication rates slightly better than cardiology fellows (0.54% compared to 0.58%). This study, carried out by Duke University in 2001, found that under the supervision of experienced attending cardiologists, trained PAs performed cardiac catheterizations with skill and efficiency. In fact, PA procedures tended to be slightly faster (p = 0.05) with less fluoroscopic time (p < 0.001) than cardiology fellows.6

Debra Pelletier, RN, BSN, Nursing Director of Cardiology Services at the North Shore Medical Center in Salem, Massachusetts, utilizes a PA in both invasive cardiology and in electrophysiology (EP). She describes the PA’s role as crucial for the smooth functioning and patient flow through the cardiac catheterization laboratories. “We do not have the luxury of cardiology fellows, so the PA role is invaluable for us,” explains Ms. Pelletier. She goes on to describe the PA in the arrhythmia service as “dynamic and a great fit for our EP program.”7

In theory, cath lab staff of any background, particularly those who have achieved the registered cardiovascular invasive specialist (RCIS) credential, would be very well prepared to transition into a PA role in the cath lab or peripheral lab if they chose to advance their career. This idea is strongly supported by the proposal to create “Advanced Level Cardiology Specialists.” The “fellow equivalents…routinely perform, with the physicians, very advanced maneuvers during cases that greatly facilitate the performance of the test.”8 The specialized knowledge of interventional procedures, radiation safety and computed imaging, including anatomy and positioning techniques, will set educated, experienced and trained personnel, and in my mind, will lead to PAs (and in the future, Advanced Level Cardiology Specialists) performing interventional procedures independently.

At this point in my clinical rotations and in preparing for interviews, I feel it is essential to approach the next challenge with my mind open, willing to learn as much as I can about each specialty in medicine. I have many interests that may steer me away from cardiology and toward an entirely new discipline. However, it is nice to know my experience and skills would be in demand if I chose to stay in invasive cardiology, electrophysiology or interventional radiology. Now, as always, it is a matter of knowing what I want, what I don’t want, and creating opportunities that suit my needs. If you are interested in the PA profession, I encourage you to plan for the journey in advance, fulfill your prerequisite courses and use your work experience in a rewarding new career.