Table 1

Case Studies of Clinician-MA Relationships

Office 1: Mature practice, physician couple owned
At this decade-old, 2-physician–owned office, the physicians personally hired all the MAs. Physicians and a senior MA who functions as a supervisor shared daily management. There was little socializing, but there were regular meetings held between the physicians and the MAs. No regular evaluations of the MAs were performed by the physician or the supervisor. There was low MA turnover. The physicians did not allow the MAs to answer patient questions without physician permission, but the MAs stated they performed this function independently. Follow-up: office has not applied for NCQA PCMH certification.
Office 2: Mature practice, formerly physician owned, now health system owned
This decade-old, 3-clinician (2-physician, 1-FNP) office was recently purchased from the physician owners by a nonprofit health system. The physicians initially hired the MAs, who were managed by the office manager; however, responsibility for these tasks was less clear under the new ownership. Frequent socializing occurred between clinicians and MAs within the office setting, and regular meetings were held between the staff and clinicians. The office manager has performed evaluations of the MAs with clinician input in the past, but not recently. There was low MA turnover. The clinicians felt they had adequately trained the MAs over the years and trusted their medical acumen to answer patient questions and provide patient education. Follow-up: office has NCQA PCMH certification.
Office 3: Mature practice, physician owner retired, now health system owned
This decades-old solo physician office was recently purchased by a nonprofit health system when the owner retired. A relatively new physician was hired for the office. The MAs included those who worked with the previous physician and new hires by the health system. The physician socialized and ate lunch with the MAs and held regular meetings with the staff. Neither the physician nor the MA supervisor performed regular evaluations of the MAs. There was MA turnover during the sale of the practice, but little since then. The clinician felt she knew the MAs from their meetings and frequent conversations and trusted their medical acumen to answer patient questions and provide patient education. Follow-up: office has NCQA PCMH certification.
Office 4: New practice, health system owned
This 2-year-old, 3-physician office was started by a nonprofit health system to build a practice that in the future might house a family medicine residency. The physicians were recent graduates. All the MAs were hired by the health system with no physician input. No physician had responsibility for training or overseeing the MAs; the MA supervisor and office manager for several primary care offices provided direct management to the MAs. There was minimal socializing at lunch or breaks between MAs and clinicians. The physicians and staff held regular meetings. There was no regular evaluation or feedback of MA performance. There was high MA turnover. The clinicians did not trust their MAs’ clinical acumen, but they did not train or oversee them. Follow up: major physician and staff personnel changes, office has NCQA PCMH certification.
Office 5: Mature practice, physician owned
At this decades-old, 2-clinician (physician, nurse practitioner), physician-owned office, the physician personally hired all the MAs and provided day-to-day management. MAs and clinicians frequently lunched on site together, there were regular meetings between staff and clinicians, and each year, the practice closed for several days and the physician took all the staff on a short vacation together. Although there was some business conducted, it was primarily a social event. The physician clearly defined both the clinical and clerical roles, but regular evaluation and feedback was inconsistent. Communication between MAs and between MAs and clinicians occasionally escalated to tears. There was little staff turnover. There were strict protocols for what clinical advice MAs could give to patients, and work was in a central area where physician was able to observe patient-MA interactions. Follow-up: office has not applied for NCQA PCMH certification.
  • FNP = family nurse practitioner; MA = medical assistant; NCQA = National Committee for Quality Assurance; PCMH = patient-centered medical home.