The Health Care System

Abstract
This chapter gives an overview of modern health care and the history of health care with an emphasis on
ambulatory care provided in a medical office. The chapter describes various types of insurance, parts of
the medical office, and members of the health care team with emphasis on those health team members
who have roles in the provision of ambulatory care. In addition, the training of physicians is covered, and
medical specialties are introduced. There is also an introduction to other types of health care including
podiatry, chiropractic, and alternative medicine.

CHAPTER OUTLINE

INTRODUCTION TO HEALTH AND THE HEALTH CARE SYSTEM MODERN TRENDS IN HEALTH CARE
HEALTH INSURANCE AND PATIENT CARE: COMPETING FORCES FACING THE MEDICAL OFFICE IN THE
21ST CENTURY

Fee-for-Service Insurance Plans

Government Insurance Plans

Managed Care

Health Care Reform

AMBULATORY CARE

Flow of Activity in Ambulatory Care

The Health Care Team

Members of the Health Care Team

Effective Teamwork

PARTS OF THE MEDICAL OFFICE

Reception Area and Waiting Room

Examination Rooms and Laboratory

Medical Records Storage and Business Office

Additional Areas Found in Many Offices

MEDICAL SPECIALTIES

Primary Care and the Patient-Centered Medical Home

Osteopathy

Podiatry
Chiropractic PRACTICE TYPES Solo Practice Group Practice Clinic

COMPLEMENTARY AND ALTERNATIVE MEDICINE LEARNING OBJECTIVES

1. Describe the role of medical office care in the health care system.

2. Describe the historical development of managed care.

3. Identify the flow of activity in ambulatory care.

4. Identify the various types of health care professionals, and describe the job responsibilities of each
professional.

5. State the educational requirements for physicians.

6. List and describe the parts of the medical office.

7. Identify and describe the various types of medical specialties.

8. Describe the philosophy of the patient-centered medical home as a means of delivering primary care.

9. Identify three medical practice types.

10. Compare and contrast various complementary and traditional medical treatments.

KEY TERMS

ambulatory (AM-byoo-la-toe-ree) care

capitation (cap-ih-TAY-shun)

curative (KYUR-a-tive) treatment

empirical (em-PEER-ih-cle)

fee-for-service

formulary (FORM-you-lay-ree)
health insurance

holistic (hole-IH-stick)

managed care

palliative (PAL-ee-a-tive) treatment

patient-centered medical home (PCMH)

quality assurance

residency (RES-ih-dense-ee)

symptomatic (simp-toe-MA-tick) treatment

utilization review

Introduction to Health and the Health Care System

The World Health Organization (WHO) defines health as the absence of illness or disease and a state of
being in which the individual feels well and is able to carry out the daily functions of life with no
difficulties and no pain. In reality, no one reaches this optimum level of health. Everyone has aches and
pains, psychological if not physical.

In our health care system, the physician's responsibility is to examine hundreds of people in the course of
a week and to try to focus on medical problems that meet the following criteria: the problem is causing or
can cause severe difficulties in carrying out the daily functions of life, and the problem can be treated
either by reducing the effects of the symptoms or by eradicating the problem altogether.

Each individual the physician sees has a different group of presenting physical symptoms and a
different set of social circumstances and emotional issues. The physician listens to the patient's
description of his or her life, performs objective laboratory and diagnostic tests, identifies medical
problems, and assesses the nature of each problem.

Physicians know that the vast majority of medical problems do not pose a long-term threat to health. Most
medical conditions get better over time. Effective treatments are available to cure many conditions
(curative treatment). In other cases the physician can reduce the symptoms even if the underlying medical
condition is not significantly affected. This type of treatment is called symptomatic treatment (responding
to symptoms) or palliative treatment (seeking to reduce the effects of a disease or condition without
curing the underlying disease). For example, a patient with a urinary tract infection who is given a
prescription for antibiotics receives curative treatment, whereas a patient who has diabetes mellitus
receives palliative treatment. The patient is prescribed insulin, which alleviates the symptoms of the
diabetes; however, the treatment does not cure the diabetes.

Most treatments are based on scientific study. In Western scientific medicine, as in no other medical
tradition, approaches to diagnosis and treatment have been studied and tested over hundreds of years. As
long ago as the 4th century BCE, a physician named Hippocrates in Greece believed that disease was not a
punishment for transgressions against the gods but rather the result of physiologic and environmental
factors that could be studied. Since the time of Hippocrates, the practice of medicine has changed
considerably in response to scientific discoveries.

Modern Trends in Health Care

Several trends running through modern medicine have a strong influence on the way in which health care
is provided in ambulatory settings.

The first trend is the desire of those who pay the bills—employers, the federal and state governments, and
insurance companies—to reduce the costs of health care, especially care for chronic diseases, and to make
health care providers responsible for effective management of patients who require care over time
without duplication of services and without medical errors. Medicare is encouraging several initiatives to
encourage doctors and other health care providers to coordinate patient care and to be accountable for
value in the care provided; these initiatives include Accountable Care Organizations (ACOs), formed
voluntarily by groups of physicians, hospitals, and other health care providers to give coordinated and
high-quality care to Medicare patients.

A second trend is to encourage the general public to become more responsible for their own good health
and management of chronic conditions. There are several public initiatives to improve dietary practices,
especially for children, to prevent obesity. Within the health care system there is an increasing emphasis
on coaching patients to manage their health and to initiate changes that will improve their health
(including dietary changes, smoking cessation, and adherence to a healthy exercise program.) The current
epidemic of addiction to pain medication has led to restrictions in most states on the amount of controlled
substances that a physician can prescribe. Many states are also requiring continuing education for
practitioners in pain management. There is a strong emphasis
on avoiding dependency on controlled substances for treatment of chronic pain by following
guidelines issued by the Centers for Disease Control (CDC) in 2016.

The third trend is an increased understanding, through empirical evidence (information learned from
experimental research), that people feel better the less they must be confined to a hospital or go to a
hospital for treatment. Being able to be diagnosed and treated in an outpatient setting with followup at
home allows people to feel more in control of their lives as medical patients. There is increasing
development of remote medicine and telemedicine applications so that patients can be monitored and
coached to health at any time.

This is especially important for people who have frequent contact with the medical system, such as the
parents of infants and children, the elderly, and those with chronic illnesses. Many people who would
have been hospitalized for long periods or possibly even institutionalized 50, 25, or even 10 years ago
are currently living independently in the community.

Currently the hospital's role is primarily to provide acute care and diagnostic services. For a patient to be
hospitalized, his or her condition must be unstable or necessitate constant regulation of therapy. If the
patient does not meet these strict criteria, he or she goes home to be followed as an outpatient; is
transferred to a rehabilitation facility for intense, regular rehabilitative treatment; or is sent to a nursing
home for long-term maintenance care.

Health Insurance and Patient Care: Competing Forces Facing the Medical Office in the 21St Century Fee-

for-Service Insurance Plans

Traditionally, medical care in the United States was paid for on a fee-for-service basis. Each service was
billed and paid for as a separate charge: so much for the office visit, so much for the electrocardiogram, so
much for the urinalysis, and so on. Fee-for-service payments can be thought of as ordering food at a
restaurant a la carte: so much for the main course, so much for a salad, so much for coffee.

During the first part of the 20th century, health insurance (if the patient had any) paid only for
hospitalization, and usually the patient completed most of the paperwork. Health insurance is a system by
which a person or the person's employer pays an insurance company a yearly amount of money, and the
insurance company pays some or most of the person's medical expenses for that year. The theory behind
insurance is that although a few people will have large medical bills over the course of the year, most
people will have small bills. By setting the fee for everyone at a level above the actual cost of care for most
people, the insurance company can pay for the care of the well, the occasionally ill, and the often ill and
still make a profit.

This system encouraged health care providers to provide a high level of care for everyone with health
insurance because the insurance paid for every test and every procedure. Physicians' incomes soared
between the end of World War II and the early 1980s. With the increasing costs of laboratory and
diagnostic testing, hospital services, and office visits, the cost of medical care increased far more
rapidly than the cost of other goods and services in the U.S. economy. (In economic terms, health care
inflation increased much more rapidly than the general rate of inflation.)

During this time, ever-better health insurance became a standard employee benefit at many
companies. The first kind of health insurance offered, in the 1950s and 1960s, was coverage for
hospital care. Coverage for office visits became standard in the 1970s.

Highlight on the History of Medical Treatment of Infectious Disease

Historians generally place the beginning of Western medicine with Hippocrates, an ancient Greek
physician who saw medicine as an independent discipline based on clinical practice rather than prayer
and ritual. For several centuries there were few treatment methods other than rest, exercise, diet, and a
few medications derived from plants. The intensive study of the human body in the 1500s fostered a better
understanding of physiologic processes. For example, the English scientist William Harvey, who rejected
the traditional belief that blood was made up of "spirits" and that body fluids were "humors," developed a
theory, later proved true, that blood flows from the heart to the lungs, throughout the body via arteries,
and back to the heart via veins.

Physician in the Middle Ages taking a patient's pulse and holding a flask of urine. (Courtesy Blocker
History of Medicine Collections, Moody Medical Library, University of Texas Medical Branch, Galveston,
TX.)
The first microscopic lens was invented in 1677 by Antony van Leeuwenhoek. Through his microscope,
van Leeuwenhoek saw yeasts, molds, and algae, adding evidence to the theory that diseases could be
caused by particles too small to be seen with the eyes. He also identified red blood cells passing through
capillaries.

Early microscope, circa 1765. (Courtesy Blocker History of Medicine Collections, Moody Medical
Library, University of Texas Medical Branch, Galveston, TX.)
Throughout the 19th century, other scientists and physicians advanced the understanding of the
cause of disease. Some found ways to combat disease without understanding the mechanism by
which the disease acted; others determined the actual cause of a particular disease.

In the 1840s the Viennese obstetric assistant Ignaz Semmelweis discovered that the number of cases of
puerperal fever, or so-called "childbed fever," a fatal illness of women who had just given birth, could be
reduced if physicians washed their hands.
Semmelweis conducted what currently would be called an epidemiologic study. He studied the records of
women who had died and determined which physicians and medical students had attended which birth.
His study of the records led him to conclude that most of the women who died had been attended to by
physicians and medical students who had come into the birthing room directly from the anatomy
laboratory, where they had worked with cadavers, without first washing their hands. Most of
Semmelweis's colleagues dismissed his notion that simple handwashing could reduce childbirth deaths as
nonsense, and during his lifetime Semmelweis was ridiculed. It was not until decades later that physicians
regularly began washing their hands.

Extracting blood for a transfusion, 18th century. (Courtesy National Library of Medicine.)

The Scottish surgeon Joseph Lister worked on similar ideas to develop the first practice of antisepsis
(cleaning areas where germs may be) and later asepsis (creating a germ-free environment). Lister started
by pouring carbolic acid on the wounds of those who had just undergone surgery. Over time, he found
milder substances. Lister found that far fewer patients who were treated with these substances died from
gangrene that developed in the open wounds.

Semmelweis, Lister, and others worked empirically, which means they sought results through
experiments that could be repeated with the same results. Although they were able to decrease infection
rates, they never completely understood what caused infectious diseases. Other scientists sought to
determine that bacteria caused specific diseases.

The German physician Robert Koch is called the "Father of Microbiology" because of his work with
specific bacteria. Koch isolated the bacterial agent that causes anthrax. Koch grew the anthrax bacillus
in a number of different liquid media in his laboratory, used the microscope to identify it, injected the
organism into a healthy animal, waited for the animal to become sick, and then recovered the same
organism from the sick animal. This proved that one specific type of bacteria causes one specific
disease. We currently know that it is possible to break the chain of illness by keeping those who are
contagious away from those who are vulnerable to disease.
The work of Louis Pasteur and Koch, among others, helped set the stage for the understanding of
infectious disease and for worldwide vaccination programs to eradicate smallpox and to try to
eradicate the "childhood illnesses" of mumps, measles, and rubella (German measles).

The first vaccination actually had been performed a century earlier. Edward Jenner, an English physician in
the farming country of Gloucestershire, used the pus from one person's cowpox lesion to vaccinate another
individual against smallpox in 1796.
Edward Jenner vaccinating an infant. (Courtesy National Library of Medicine.)

Cowpox is a variant of smallpox. It is lethal to animals but relatively harmless to humans. For
centuries, people had realized that people who had been infected with cowpox did not develop
smallpox. We currently understand what happened—their immune systems had developed
antibodies to cowpox that also prevented smallpox infection by attacking the smallpox virus.

Jenner used "humanized cowpox" to establish immunity by taking pus from a lesion on a human infected
with cowpox and rubbing it into an open wound on another human. A couple of weeks later, he inoculated
the second person with smallpox. Not only did the individual not become ill, but he also was not
contagious. A century later Pasteur would discover fully the mechanism by which vaccination works.
Vaccines were discovered for many diseases. By the beginning of the 20th century, vaccines had been
developed for diphtheria and tetanus, and most children received these vaccines as infants by the middle
of the 20th century. New immunizations continue to be developed not only for infants but also for
adolescents, adults, and the elderly.

Medications to kill bacteria were another important tool in the fight against infectious disease. Paul Ehrlich
is credited with the development of the first medication to kill bacteria. In 1909 he developed a drug called
Salvarsan (arsphenamine), which could be used to effectively treat syphilis. Unfortunately the medication
itself was extremely toxic. The first of the sulfanilamide drugs, Prontosil, was developed in 1932 in
Germany. It was effective against infections caused by streptococci and some other types of bacteria. The
sulfanilamides became popular before and during World War II because they were the only antiinfective
agents widely available. Penicillin, a mold that kills bacteria, had been discovered in 1922 by Alexander
Fleming in London after it attacked bacteria that he was growing on agar plates. Initially the scientific
community did not believe that it would be effective inside the body, and little follow-up research was
done. During World War II, two medical researchers, Howard Florey and Ernst Chain, took up the research
on penicillin and managed to prove that the medication was effective. The first human was treated in 1941,
and within a few years mass production had been established and penicillin was in widespread use.

Discovery of the first virus is credited to Dimitri Ivanowski, a Russian botanist, in 1892. He discovered
that a substance could pass through a ceramic filter that trapped all known bacteria and still cause a
disease of tobacco called mosaic tobacco disease. We now know that the culprit is the tobacco mosaic
virus. Yellow fever was the first viral disease of humans to be identified. During construction of the
Panama Canal, workers were devastated by this disease. Research done by Walter Reed established that
the disease was caused by a virus transmitted by mosquitoes and not direct contact. Controlling
mosquitoes facilitated the work on the canal. The development of the electron microscope in 1930
allowed viruses to be seen, but progress to control viral diseases was slow. For most viruses the body has
adequate defenses to overcome the infection, but there are some significant exceptions. The retroviruses,
such as human immunodeficiency virus (HIV), are notable because they are able to overcome the body's
immune system. In the 1970s the first deaths from acquired immunodeficiency syndrome (AIDS) were
reported in the United States. Within the next 20 years, a worldwide epidemic occurred. By 1997 more
than 6 million deaths worldwide had been caused by the AIDS virus. Treatments have been able to control
the progression of the disease for many years, but to date there is no effective immunization or cure for
this disease. The ability of
viruses to mutate rapidly has resulted in recent viral pandemics from diseases such as severe acute
respiratory syndrome (SARS) in 2004 and H1N1 influenza in 2009. ■

Government Insurance Plans

Recognizing that there were large segments of the population without insurance because they were not
employed, the federal government began to provide health insurance to large segments of the population
starting in the 1960s. Medicaid began to provide health insurance for low-income children without
parental support and later expanded to cover all the medically indigent. Medicare initiated health
insurance for the elderly, the disabled, and those with end-stage kidney disease. The Civilian Health and
Medical Program of the Uniformed Services (CHAMPUS; currently called TRICARE) provided health
insurance for dependents of active-duty military personnel. With these programs, the federal government
has become the primary insurer for more than 50 million Americans. These plans, which included
payments for office visits for illness, greatly increased the number of Americans who had medical
insurance. There was little incentive for the consumer (the patient) to control costs because insurance was
covering those costs and care in most cases was "free" to the consumer.

Although most Americans who were insured did not feel that they were "paying" for their medical care,
they were, indirectly. The huge increases in health care costs were one of the major sources of the
generally high rates of inflation in the 1970s. Employers who paid for the insurance had to pay ever-
rising premiums and offset these large premium increases with small increases in cash wages, which did
not keep up with inflation. So American workers did, in fact, pay for health insurance and health care
costs in lower purchasing power for the cash they received as salary.

Managed Care

Health Maintenance Organizations (HMOs) were originally formed with a belief that consistent, routine
care would help to prevent later expensive care. Managed care was based on the belief that increasing
prevention and promoting early detection and diagnosis of chronic and life-threatening medical conditions
would reduce costs. At that time traditional health insurance covered only office visits for illness or injury
and did not cover so-called "routine care" (well-child visits, immunizations, regular checkups, or physical
examinations). The HMO movement, which gained acceptance in the 1970s, pushed traditional health
insurance companies to begin providing coverage for routine care.
In the late 1970s, insurance companies began to respond to escalating health care costs by reviewing care
to find out if it was medically necessary. This process, called utilization review, identifies patients who,
according to the insurance companies, no longer need to be hospitalized. Originally, utilization review was
used by Medicare and Medicaid and only for hospitalized patients. Other insurance companies soon
realized that shortening hospital stays was an important way of reducing overall health care costs. The
combination of HMO insurance plans and strict utilization review for hospitalized patients is the basis of
what we call managed care. Utilization review is currently used for both inpatients and outpatients to
control health care costs.
The original HMO model had two components: insurance and services including diagnostic tests and
pharmacy. HMO plans set up full-service medical clinics. Physicians were employees. The HMO
established a contractual relationship with a hospital for inpatient services, and patients had to go to the
specific hospital with which the HMO had a contract.

In the late 1980s HMO services began to separate from HMO insurance. A second type of HMO model
based on networks of physicians who agreed to provide care for HMO patients came into being. Some of
these networks operated under the old fee-for-service plans but agreed to discounted fees from the
HMOs in exchange for access to the rapidly growing patient populations enrolled in HMOs. In an effort to
reduce payments, HMOs tried to have physicians accept a flat monthly fee for each subscriber in their
practice and agree to provide all necessary primary care for that fee. This type of payment is called
capitation. This reduces the incentive to provide extra services because their cost will not be reimbursed
separately.

A quality assurance plan is required by each state for HMO insurance plans. Quality assurance ensures
that patients receive safe and appropriate services. This is accomplished by planned review of data about
the types and effectiveness of services provided to patients of the HMO.

The managed care movement in general, as well as the trend to decrease reimbursement for primary care
in particular, put the burden on physicians to compete with one another to provide the most care for the
least money. As a result, physicians often feel pressure to limit diagnostic tests, reduce hospitalizations
and the number of days patients stay in the hospital, and use generic instead of brand-name drugs.
(Generics are identical in chemical formulation to brand-name drugs and can be manufactured only after
the brand-name drug's patent protection has expired.)

Managed care also puts pressure on physicians to see more patients, spend less time with each patient,
and justify all services including diagnostic tests and referrals. The expense of handling sicker patients is
expected to be balanced by those patients who use less than the average amount of medical services.

In addition, insurance plans have tried to reduce their costs for prescription medications by restricting
drug coverage to lists of approved drugs. Such a list, called a formulary, usually includes one or two of
the less expensive drugs for each possible medical condition. Exceptions are made if the physician can
show that the less expensive drugs have been ineffective for his or her patient or cannot be used because
the patient is allergic to them and that a more expensive drug is necessary. In some plans the patient can
receive a more expensive medication by paying more of the cost.

Health Care Reform

Despite these measures, beginning in the late 1990s, both insurance premiums and health care costs began
to increase at more than double and even triple the underlying rate of inflation. There has also been an
increase in the number of individuals and families who do not qualify for government insurance plans and
also do not have health insurance through their employers. This may be because they work part-time or
are self-employed. The Patient Protection and Affordable Care Act, which
became law in March 2010, expanded insurance coverage to an estimated 32 million Americans who were
previously uninsured. Among the provisions that went into effect in September 2010, insurance
companies are no longer allowed to exclude children with preexisting health conditions or to drop
customers after discovering technical mistakes on applications. As of 2014 this law required all
individuals to purchase health insurance or pay an annual fine. Even though this part of the law is no
longer in force, a strong belief persists that society has an obligation to make appropriate health care
accessible to all citizens.
Ambulatory Care

There is no such thing as a "typical" medical office. The style of any particular medical office depends on
the personality of the physician or physicians who practice there, as well as the general population of
patients who come there. Regardless of the physician's personality and the patients' personal
backgrounds, the same kinds of activities occur in any physician's office setting.

Currently, the trend in medical care is toward an increasing amount of ambulatory care-defined as the
patient coming to the care rather than the patient receiving care in a home or hospital setting (Fig. 1.1). To
take advantage of ambulatory care, the patient must be able to walk into the physician's office or at least
be brought to the office in a wheelchair. In addition to private physicians' offices, offices of physicians who
make up a staff model HMO, community health centers, multispecialty clinics, and hospitals are
increasingly making more space available for outpatient care.

FIG. 1.1 The patient check-in area in a clinic.

Flow of Activity in Ambulatory Care

The flow of activities for each patient in an outpatient setting is similar. The patient will do the
following:

• Enter the office.

• Approach the reception desk, identify the physician and time of appointment, provide the office staff
with personal and payment information, and make a copayment (if necessary).
• Be seen by a physician (or by a nurse practitioner [NP] or physician assistant [PA] if the practice uses
such personnel).
• Undergo diagnostic or laboratory tests in the office.

• Receive a diagnosis, treatment, or a referral to another health care provider.

• Receive instruction for follow-up care and any laboratory or diagnostic tests to be done elsewhere
before leaving the medical office; if seriously ill, the patient may be admitted to the hospital.
Fig. 1.2 is a flowchart of how a patient moves through the medical office.
FIG. 1.2 Patient progress through a medical office.

Once a patient has been seen in the medical office, the office begins the process of obtaining payment for
its services. The medical payment may come from a private insurance plan, a government-funded
insurance program, and/or from the patient. The patient may be responsible for a percentage of the
charges or the entire bill if he or she does not have insurance.

After the examination, the patient receives instructions to prepare for a test or procedure to be performed
or information about medication that has been prescribed. Patients who are seen regularly because of a
chronic illness may spend time with a physician or medical assistant reviewing the patient's individual
treatment plan. A follow-up appointment is made if necessary.

Most medical offices provide health education materials in print or online. These materials may
consist of pamphlets, article reprints, health education videos, or health news reports specially
prepared for viewing in the medical office.

The Health Care Team

A medical assistant works as a member of a dedicated health care team. The physician or group of
physicians expects each medical assistant to fill a slightly different role within the office team. This role
will depend on the style of the practice, the region of the country where the practice is located, and what
types of medical professionals make up the team.

As the operations of a medical practice become more complex, physicians may employ individuals with
more specialized medical business and medical management experience to run the business side of the
office. In these offices, medical assistants play more of a clinical role. In smaller offices, medical
assistants usually perform both clinical and administrative activities.

Putting It All Into Practice

My name is Aida Reyes, and I am the Medical Assistant for a primary care physician. I have been working
here for 12 years, and in that time it has gotten busier and busier. We used to see about 15 patients in a
typical morning or afternoon, and now we are seeing an average of 20-25. When I first took the job, I
thought it would be a fairly relaxed environment. How busy could it be with only one physician? Since I
first began, our practice has merged with another practice and expanded, so that there are now four
physicians and two nurse practitioners. We are now affiliated with a large medical group that does the
billing centrally, so that I primarily work with my physician, preparing patients for examination, queuing
up medications that need to be refilled for the physician, keeping the examination rooms stocked, taking
vital signs and doing other previsit work, then preparing patients
for follow-up laboratory testing and making sure that we receive all test results back. I also call patients
who have not come in when they are scheduled and help with referrals for my physician's patients
(because so many patients have some type of managed care insurance). ■

Members of the Health Care Team

The members of the medical team who typically work in ambulatory care, be it a private practice, a
community or public health clinic, or a hospital clinic, include physicians, NPs, PAs, medical assistants,
registered nurses (RNs) or licensed practical nurses, a business manager, a receptionist, a medical
secretary, file clerks, and one or more insurance specialists. Medical transcription is occasionally done in
the medical office, but increasingly it is outsourced or replaced by the electronic medical record or voice
recognition software. If the office performs moderate- or high-complexity laboratory tests, a certified
medical technologist may also be on the staff or serve as a consultant.

Hospital or community-based clinics will possibly also have a staff of social workers, outreach workers,
and case managers to provide social services to patients. Practices specializing in women's health
(obstetrics and gynecology) may also have certified nurse-midwives.

Table 1.1 lists various nurses and allied health professionals and describes their roles.

Table 1.1

Nurses and Allied Health Professionals Occupation Credentials Responsibilities

Certified Professional Coder CPC Assigns codes to patient charges and diagnoses for insurance
billing. There are many additional coding certifications depending on knowledge and specialty.
Certified Coding Associate CCA

Certified Coding Specialist CCS

Diagnostic Medical Sonographer DMS Performs ultrasound scans in hospitals and

ambulatory care facilities. Ultrasound uses high-frequency sound waves to produce images. A sonographer
may specialize in ultrasound of the heart (echocardiography).
Emergency Medical Technician

Paramedic

EMT; paramedic Provides emergency services and life support in the community. Several
levels of emergency service personnel exist, depending on training and experience.
Health Information Specialist RHIA; RHIT Works with patient medical records; may provide assistance
in planning, managing information, gathering data for medical research, and policy making.

Registered Health information Administrator RHIA

Registered Health Information Technician RHIT

Medical Assistant CMA (AAMA); RMA Performs administrative and clinical tasks in ambulatory care.
There are also other certifications.
Certified Medical Assistant (AAMA) CMA (AAMA)

Registered Medical Assistant RMA

Medical (Laboratory) Technologist MT; MLT Performs laboratory tests in the clinical
laboratory and may supervise laboratory operations or provide consulting services.
Medical Secretary CMS Secretary who specializes in administrative procedures in a health care setting.

Certified Medical Secretary CMS Nuclear Medicine Technologist

Certified Nuclear Medicine Technologist

CNMT Operates devices that detect and map absorption of radioactive substances given by injection to
create diagnostic images.
CNMT

Nurse, Practical LPN; LVN Performs direct patient care and clinical procedures. May work in
hospitals, nursing homes, and ambulatory care settings.
Licensed Practical NurseLPN

Licensed Vocational Nurse LVN

Nurse Practitioner NP Specializes in a specific area such as internal medicine, pediatrics, or

women's health, and often manages routine patient care in ambulatory care settings.
Nurse, Registered RN Plans and provides nursing care in inpatient settings. Provides
supervision for caregivers in both inpatient and outpatient settings.
Occupational Therapist

Occupational Therapy Assistant

OT; OTA Plans therapeutic activities for rehabilitation, especially for activities of daily living (ADLs).
Implements treatment plans.
Physical Therapist

Physical Therapy Assistant

PT; PTA Plans exercises for large muscle groups for rehabilitation and implements treatment plans.

Physician Assistant PA Manages routine patient care under the supervision of a physician.
Usually works in ambulatory care.
Radiologic Technologist RT Takes radiographs and assists with special radiographic examinations. After
completing education, may specialize in computed tomography, mammography, or therapeutic radiation.
Registered Dietician RD Assists with nutrition of patients in hospitals and ambulatory care.
Performs nutrition screening and counseling. Coordinates all aspects of food service in many settings.
Respiratory Therapist RRT Provides respiratory treatments and manages patients on ventilators.
Surgical Technologist CST Assists during surgery in hospital and day surgery centers by setting up
operating rooms, preparing instruments and equipment, and passing instruments during surgery.
CMS, Centers for Medicare and Medicaid Services.

Physicians and Other Health Care Providers

Physicians have either an MD (medical doctor) or a DO (doctor of osteopathy) degree, either of which is
awarded after 4 years of college, then 4 years of medical or osteopathic school. In addition, they complete
a hospital-based, intensive postgraduate training period, traditionally called a residency, which lasts
from 2 to 7 years, depending on the specialty. To receive a medical license from the state where he or she
will practice, the physician must pass parts I, II, and III of the U.S. Medical Licensing Examination
(USMLE). The first two parts of the examination are taken during medical school, but part III cannot be
taken until the physician has completed at least 1 year of residency (sometimes called an internship).

If a physician wants to be "board certified" in a specialty, he or she must pass another examination,
administered by the certification board of the particular specialty. The physician does not need to be
board certified to obtain a state license to practice medicine.
A PA must have at least 2 years of college plus 2 years of PA school, although most PA programs award a
master's degree. A PA usually specializes (e.g., in pediatrics, in adult medicine) and manages a group of
patients receiving routine care. He or she must practice with a physician. All states have laws regulating
PAs, and students must pass the national certification examination to obtain a state license.
An NP is an RN who has completed a program in advanced practice nursing, a program that usually grants
a Master of Science in Nursing (MSN) or higher degree. NPs can specialize in pediatrics, family practice,
gerontology, or other specialty areas. In primary care, NPs help with all aspects of patient care, including
physical examination, diagnosis, treatment, consultations, and patient education. They may serve as a
patient's primary care provider. They are licensed as NPs by the state in which they practice.
The educational requirements and scope of an NP's ability to practice independently are determined by
each state. In all states, NPs are allowed to carry a caseload and manage routine patient care. All states
allow NPs to write prescriptions with varying degrees of supervisions. In some states, NPs are also
allowed to practice independently, but in most they must practice in an office with supervision by a
physician. In a few states, NPs are allowed to admit patients to hospitals.

What Would You Do? What Would You Not Do?

Case Study 1

In the examination room, Alicia Darwin, a new patient, tells Aida that she has switched physicians because
she had often been seen by a nurse practitioner in the medical office where she used to go. "I don't think a
nurse practitioner has as much experience as a doctor," she says, "and besides, the nurse practitioner can't
give me medication if I need it." She asks Aida to confirm that she will always be seen by the physician in
this office. She adds, "I don't have anything against nurses like you; I just want to have a real doctor take
care of me." ■

Effective Teamwork

Working as an effective health care team does not just happen. To be effective, team members work
together to provide appropriate care for each patient. The more people involved, the more crucial this
teamwork is. Each member of the team must be committed to problem solving, communicating, and
coordinating effective care.

Teamwork is reinforced at regular staff meetings, which can be directed by either the medical or the
business director of the office, depending on the particular topics of the meeting. However, the true test of
teamwork occurs on a daily basis as health care is provided.

Each health care team member has certain responsibilities and restrictions on activities and areas about
which he or she is allowed to make decisions. Sometimes this scope is defined by federal or state law. For
example, medical assistants are allowed to administer injections in some states, but in others they
cannot. The medical assistant must learn what areas fall within the proper scope of practice and
decision-making responsibility in his or her state.
The specific education and role of the medical assistant is discussed in Chapter 2. The medical assistant
plays an important role by keeping the work of the office flowing smoothly. He or she must communicate
well with other health team members. Because a patient will not always repeat all information to the
physician, the medical assistant must communicate anything related to the patient's health verbally or
through the medical record. At the same time, the medical assistant must be careful to avoid giving
medical advice to the patient (unless following specific guidelines established by the physician).

Teamwork is enhanced when each team member helps and supports other members and avoids blaming
or criticizing others. Because the number of employees in a medical office is often small, it is important for
everyone to do his or her best to get along and deal with conflict. When a problem arises, it is important to
try to find solutions to the problem rather than focusing on who caused the problem or whose fault it is. It
is also helpful to maintain perspective and accept that things do go wrong and that most problems can be
dealt with. In any conflict situation, it is important to listen to the point of view of others and validate their
feelings. Effective communication techniques are discussed in more detail in Chapter 4.

Parts of the Medical Office

A physician's office has a number of different physical spaces in it. Each space has a particular purpose.
Every physician's office has three basic areas: a reception area and waiting room, examination and
treatment rooms, and an area for other activities. This may include medical records storage, if the office
uses paper medical records; storage for supplies; and staff offices or cubicles.

In most offices, physicians also have their own offices, separate from examination rooms, but some
physicians have examination tables in their offices, combining the two spaces in one room.

Larger offices may have several additional areas such as an office laboratory; separate treatment
rooms or special procedure rooms; a business office, which is separate from the front office
(reception, telephones, appointments); and a lunch or break room for the staff.

All physicians' offices must meet a number of specifications laid out by regulatory agencies. These include
the federal Occupational Safety and Health Administration (OSHA), which regulates workplace health and
safety. Physicians' offices also must meet the specifications of the Americans with Disabilities Act, which
requires that doorways be at least 3 feet wide and hallways at least 5 feet wide. Restroom facilities must
be available for both patients and staff. Office laboratories are regulated by the Clinical Laboratory
Improvement Amendments of 1988 (CLIA '88). Local boards of health also inspect and regulate hospitals
and clinics.

Fig. 1.3 shows the layout of a small medical office.

FIG. 1.3 Layout of a small medical office.

Reception Area and Waiting Room

The reception area and waiting room are the first place any new or prospective patient will see. First
impressions are important. The waiting room should be clean and well lit. Furniture should be arranged
and not haphazardly placed. Up-to-date, general-interest reading material should be available; many
physicians also have patient education materials available in the waiting room. Waiting rooms in
pediatric and family practice offices also have toys available for children. Large pediatric practices may
have a separate waiting room for sick children or for adolescents.

The waiting room should have enough chairs for two people per patient visit, multiplied by the number of
patients seen in 2 hours. It needs to present a calm atmosphere and look professional. Usually the waiting
area is carpeted. It should have comfortable chairs, grouped in blocks, if possible, rather than just lined up
around the walls. Colors should be muted, and music should be soft. Red, yellow, and orange are typically
avoided; currently, physician's office decor often uses shades of green, dusty pink, or salmon. Music may
be played from a CD or radio station of the "easy listening" variety, or there may be a television in the
waiting room.

The reception area adjoins the waiting room. The medical assistant at the reception desk should greet
each patient as he or she enters the waiting room. Most reception areas have a counter so that the patient
can fill out or sign forms, and many have a sliding window so that patients cannot hear the conversations
occurring behind the receptionist.

Patients check in here when they enter the office. New patient forms are received here, and health
insurance cards are copied or scanned. Copayments are taken from patients whose insurance is provided
through HMOs. Appointments may be made by the receptionist or in a separate area of the office.

Examination Rooms and Laboratory

Examination rooms are designed for the convenience of the physician and assisting personnel who will
work there. However, they also need to be as comfortable and calming to the patient as possible. Reading
material should be available in each examination room. Although good scheduling will ensure that
patients will not wait too long in these rooms for a physician, most physicians do see patients in at least
two examination rooms. Additional delays may occur if the physician has to respond to urgent telephone
calls or office emergencies (Fig. 1.4).
FIG. 1.4 Examination rooms are usually compact, but each should be large enough to accommodate a
wheelchair. (From Proctor D, Adams A: Kinn's the medical assistant, ed 12, St. Louis, 2014, Saunders.)
Many physicians perform treatments or diagnostic procedures in examination rooms, but complex
procedures (such as suturing a laceration) are often performed in larger rooms with extra equipment
and/or supplies. These are called treatment rooms.

If laboratory tests are performed in the medical office, there is a special room or area set aside for this.
CLIA '88 regulates laboratory testing. Medical assistants are trained to perform low-complexity tests
(CLIA-waived tests) such as dipstick urinalysis, urine pregnancy tests, and rapid strep tests. They may also
perform more complex texts with special training.

CLIA '88 specifies who can supervise laboratories and lays out the process for inspection and
accreditation. It sets strict guidelines for quality control, quality assurance, handling of hazardous
materials, documentation, and proficiency training. Offices that perform only CLIA-waived laboratory tests
may perform laboratory testing in the patient preparation area. Ideally the bathroom is adjacent to this
area, with an opening in the wall so that urine samples can be passed directly into the laboratory area.
Medical Records Storage and Business Office

If the office uses paper records, the medical records may be stored near the reception area, in the business
areas, adjacent to the patient preparation area, or in a separate room. Charts of active patients—those
who have been seen within the past 2 to 3 years—are kept in the records storage area in the office.
Inactive charts are removed regularly and stored in a less accessible location such as the basement of the
building or off-site in a facility that maintains records in storage. Charts needed for patients who will be
coming in during a specified period—morning, afternoon, or an entire day—are removed from the storage
area and prepared for use.

The majority of medical practices have moved away from paper records to computerized medical
records. In this case, patient records are stored on a computer's hard disk and are simply pulled up from
the database as needed. The process of placing old records into the computerized record is lengthy, and
some offices that use an electronic health record store the former paper records of established patients in
an accessible area for 1 to 2 years after the transition to the electronic health record.

Posting of patient charges, billing, and computer operations may be performed in an area behind the
reception desk or in a separate business office. If the practice has one or more satellite locations, the billing
and insurance tasks are usually done in the practice's main office for all locations. Some offices contract
billing and insurance claim processing to an outside company, which may even be located in another state.

What Would You Do? What Would You Not Do?

Case Study 2

The physician complains to Aida that there are always dishes in the sink in the break room and crumbs
and used paper coffee cups on the table. Even though the area is not seen by patients, the physician is
concerned that an insect or rodent problem could develop. Aida knows that the parttime file clerk and
the part-time receptionist have a tendency to leave dirty dishes and trash after their afternoon break.
She herself is so busy that she rarely has time to either clean or sit down in the break room. ■

Additional Areas Found in Many Offices

Physicians' private offices are often a reflection of their personal tastes. This room is where a physician
meets privately with patients, patients' families, and other visitors. He or she usually displays degrees and
certificates of membership in professional organizations on the walls of the office. Even if the practice has
a small library for the use of all staff, physicians will usually have at least a few important references in
this office. Art and memorabilia that show the physician's personal taste also help to make the private
office a pleasant place for the physician to do quiet work and hold meetings.

Recognizing the needs of staff for a quiet place to take their breaks and eat their lunch, newer offices and
large offices often include a staff break or lunch room. This room may have a refrigerator and microwave
for staff to prepare lunches they bring from home. There should be at least one table and chairs. The lunch
or break room should not double as a storage area, and staff should avoid using the room for meetings
that deprive others of use of the room.

Depending on the type of medical practice, particular rooms may be set aside for specific treatments or
diagnostic procedures. Types of special rooms include the following:

• A pediatrics examination or treatment room in a family practice group's office

• A surgical procedure room in a general surgery group's office

• A room for more complex testing such as colposcopy and pelvic ultrasounds in a group practice
specializing in obstetrics and gynecology
• A trauma room in a large clinic or community health center

Memories from Practicum

Aida Reyes: The clinic where I did my practicum was so large that at first I kept getting lost. Another thing
that confused me was the doors that the staff used to get from one part of the clinic to another. It was
arranged by department, but the layout of rooms in each department was different. I spent the majority of
my time in internal medicine working with one medical assistant and one physician, but my preceptor
arranged for me to spend time in other departments such as medical records, billing, and pediatrics and
with the referral coordinator. In addition to the full-time physicians, there were some specialists who
came in once or twice a week, including a neurologist, an orthopedic surgeon, and an ophthalmologist.
The clinic also employed a social worker and a dietician. In each department there was a nurse and there
were at least two medical assistants in addition to the receptionist. The amazing thing was how quickly I
adapted and became comfortable finding my way around. After only a few weeks, it felt like I belonged
there. I was so proud when my preceptor said, "Aida, you have become one of the team. I don't know how
we ever got along without you." ■

Medical Specialties

Since the middle of the 20th century, the practice of medicine has been broken down into fields of
specialty and subspecialty. In 1950 most Americans received their medical care from a general
practitioner, who took care of adults and children, often delivered babies, and performed many general
surgical procedures.

Currently, Americans may see two, three, or more physicians routinely. Box 1.1 describes the medical
specialties in which a physician can be board certified according to the American Board of Medical
Specialties. In many areas, there are several subspecialties. If the physician wants to become certified in a
subspecialty, after the residency training he or she participates in additional training called a fellowship
for 2 to 3 years. It is not possible to be board certified in any specialty or subspecialty without completing a
residency.

Box 1.1

Specialties in Which the American Board of Medical Specialties Offers Certification.

Allergy and Immunology (Allergist, Immunologist): Treats adults and/or children with allergies and
problems of the immune system. Many individuals experience allergies and/or asthma in the presence of
allergens. The immune system can also malfunction either through inherited or acquired diseases.
Allergists and immunologists diagnose, manage, and treat allergic diseases, immunodeficiency conditions,
and autoimmune diseases.
Anesthesiology (Anesthesiologist): Provides anesthesia during surgery and other procedures, as well as
medical care to patients before, during, and after surgery. The anesthesiologist also supervises other
anesthesia personnel in the operating room such as nurse anesthetists and anesthesiology residents.
Colon and Rectal Surgery: Performs surgical treatment of the large intestine and rectum. These surgeons
specialize in the diagnosis and treatment of diseases of the colon and rectum in addition to full training in
general surgery. They perform diagnostic and screening procedures and perform surgery when necessary.
Dermatology (Dermatologist): Specializes in conditions of the skin. Dermatologists diagnose skin diseases
and also perform surgery on the skin. Laser treatments are commonly used for skin conditions in addition
to medication, cryotherapy, and surgery.
Emergency Medicine: Treats patients for emergency conditions, usually in the emergency department of a
hospital. Emergency medicine focuses on treatment of acute illnesses and injuries that require immediate
care. The physician is often an employee of a hospital emergency department or other urgent care center.
Family Medicine (Family Practitioner): Treats adults and children for routine care and complaints; often
the primary care physician for all family members. The family practitioner is concerned with the total
health of the individual and the family.
Internal Medicine (Internist): Provides medical treatment for conditions of various body systems. The
internist may be the primary care provider for adults. Within the discipline of internal medicine there are
several subspecialties based on patient age groups, body system, or type of disease.
Medical Genetics and Genomics: Provides diagnostic procedures and treatment for individuals with
genetically linked diseases. Also provides genetic counseling and prenatal diagnosis.
Neurological Surgery (Neurosurgeon): Performs prevention, diagnosis, surgical and nonsurgical treatment,
and rehabilitation for conditions of the brain, spine, and nervous system. Also provides surgical and
nonsurgical treatment of pain.
Nuclear Medicine: Specializes in diagnosis using radionuclides, atoms that give off electromagnetic
radiation. Nuclear medicine physicians (also called nuclear radiologists) are usually employed by a
hospital or university (or both) and have little direct patient care. They are responsible for diagnosis and
recommending treatment of abnormalities detected through the various imaging modalities used in the
nuclear medicine department.
Obstetrics (Obstetrician) and Gynecology (Gynecologist): Specializes in care during pregnancy and
delivery (obstetrician); specializes in other care and surgery of the female reproductive system
(gynecologist). The gynecologist is responsible for screening procedures, diagnostic procedures, and both
medical and surgical treatments. He or she also frequently uses hormone-modulating treatments.
Ophthalmology (Ophthalmologist): Specializes in the care of the eye. The ophthalmologist manages
diseases and conditions of the eye with both medical and surgical treatment including laser treatments.
May also manage errors of refraction and prescribe corrective lenses, although this is often delegated to an
optometrist.
Orthopedic Surgery (Orthopedic Surgeon): Specializes in diagnosis and treatment of acute and traumatic
injuries of the musculoskeletal system, as well as diseases of the muscular or skeletal system. Both surgical
and nonsurgical treatments are used. A subspecialty is sports medicine.
Otolaryngology (Otolaryngologist or ENT): Specializes in the care of the ear, nose, throat, head, and neck.
The physician, often called an ENT (for ear, nose, and throat), is responsible for the diagnosis and surgical
or nonsurgical treatment of a variety of disorders affecting the specified organs.
Pathology (Pathologist): Examines cells, tissues, and other specimens to determine whether their structure
is normal or abnormal; attempts to determine the nature or cause of disease. Pathologists examine tissue
biopsies and other specimens to identify abnormal cells. They also perform autopsies.
They may be trained within two primary specialty areas: clinical pathology and/or anatomic pathology.
Pediatrics (Pediatrician): Specializes in the care of children from birth through adolescence. In the United
States, pediatricians are considered to be primary care practitioners. However, many pediatricians
specialize, and almost every specialty for adult medicine is represented as a pediatric subspecialty.
Physical Medicine and Rehabilitation (Physiatrist): Specializes in the treatment and rehabilitation of
patients with disabling conditions such as spinal cord injury and stroke. A physiatrist sees patients across
several age groups and specialty areas and focuses on restoring maximal function to patients. He or she
may specialize in specific age groups or types of injury such as spinal cord injury.
Plastic Surgery: Specializes in surgical and nonsurgical treatment of physical defects of various areas of the
body. The plastic surgeon performs procedures for cosmetic enhancement or reconstruction of various
parts of the body. Cosmetic surgery has become popular in the past two decades. Reconstructive surgery
includes craniofacial surgery, hand surgery, and maxillofacial surgery to repair congenital defects and
problems that result from injury or disease.
Preventative Medicine: Includes aerospace medicine, occupational medicine, and public health. In this
medical specialty, physicians practice in one of the specialty areas or one of the subspecialties (addiction
medicine, clinical informatics, medical toxicology, or undersea and hyperbaric medicine).
Psychiatry (Psychiatrist) and Neurology (Neurologist): Specializes in preventing, diagnosing, and treating
mental illness and/or diseases of the nervous system. Psychiatrists have completed the same general
training as any other physician, and they are able to prescribe medication for mental illness and monitor
the effects of medication therapy. Like other mental health professionals, they usually also have training in
psychotherapy, psychoanalysis, and/or cognitive behavioral therapy.
Neurologists have training in diseases of the central and peripheral nervous system. Subspecialties include
addiction psychiatry, brain injury medicine, neurodevelopmental disabilities, pain medicine, sleep
medicine, and others.
Radiology (Radiologist): Specializes in the use of x-ray and other ionizing radiation for diagnosis
(diagnostic radiology), treatment (radiation oncology), or medical physics. A diagnostic radiologist has the
training to manage several types of diagnostic imaging including x-ray studies, computed tomography (CT)
scans, and magnetic resonance imaging (MRI).
Surgery (General Surgeon): Performs general surgical procedures. A general surgeon performs primarily
abdominal or vascular surgery using traditional methods or laparoscopic methods. Hand surgery may be
performed by a general surgeon or a plastic surgeon.
Thoracic Surgery (Thoracic Surgeon): Performs surgery of the chest including cardiac surgery, although
thoracic surgeons usually specialize in surgery of the chest or cardiac surgery.
Urology (Urologist): Specializes in the care of the urinary system in males and females and the
reproductive tract in males; also specializes in surgery of the urinary tract and male reproductive tract.
The urologist may provide medical treatment for infections or surgical repair for abnormal growths or
correction of congenital malformations.
Primary Care and the Patient-Centered Medical Home

Primary care physicians specialize in internal medicine (treatment of the internal organs of adults by other
than surgical means), pediatrics (general medical care of children and adolescents), or family
medicine (general medical care of children, adolescents, and adults—the current equivalent of
general practice).

Over the course of time, the activities of different types of physicians have shifted. For instance,
currently fewer family practitioners deliver babies than did general practitioners in the 1950s and
1960s, preferring to leave that task to obstetricians, owing in part to the cost of malpractice insurance.
Although some women continue to see a gynecologist for an annual pelvic examination and Pap test,
the primary care provider is usually also willing to perform these activities.

Primary care has been greatly influenced in the past decade by the movement to establish a patient-
centered medical home (PCMH) as the provider of a patient's primary care. The PCMH is a model of
primary care that emphasizes patient-centered health care based on a personal relationship between a
patient, a physician, and the patient's care team. The PCMH movement incorporates several elements:

• It is patient-centered, and health care teams are jointly responsible for patient care and safety.

• It is comprehensive, including prevention, acute care, and chronic care.

• Care is coordinated across the entire health care system including specialty care, hospitals, home care,
and community services.
• Patients receive high-quality care; both patients and families are encouraged to make informed
decisions about their health.
Most states have adopted an initiative to support the PCMH movement and encourage primary care
practices to become recognized PCMHs. There is a strong relationship between PCMH practices and ACOs
mandated by the Centers for Medicare and Medicaid Services (CMS), which are intended to increase the
quality of care of Medicare patients. Within the PCMH movement, medical assistants play an important
role in enhancing access to care. They are often expected to undertake more advanced duties than were
formerly assigned to them.

Osteopathy

Osteopathy is a mix of traditional scientific medicine and holistic medicine, which focuses more on healing
the entire person than a specific disease or condition. This branch of medical practice seeks to balance the
structure and function of the body through manipulation of muscles and joints. Osteopathy was started in
the late 1800s by Andrew Taylor Still (1828-1917). Osteopaths see disease as the result of dysfunction in
the skeletal and muscular systems. Pain, "asymmetry" (the difference in anatomy or joint movement
between one side of the body and the other), and tissue tenderness are used to gauge symptoms.
Osteopaths, who hold DO degrees, currently are given all the privileges of those with MD degrees. The
majority of osteopaths practice as primary care doctors, where they believe their holistic and structural
approach can be most effective.
Podiatry

Podiatrists use traditional medical and surgical techniques but are limited in their practice to treatment
of disorders of the feet and ankles. Since the 1970s, podiatry has worked to enlarge its area of practice
by focusing on surgery of the foot to alleviate such problems as bone spurs and bunions. Podiatrists
work closely with primary care doctors in the management of diabetic patients and the elderly, who
often require specialized foot care.

Chiropractic

Contemporary chiropractic care focuses on the evaluation of neuromuscular and skeletal disorders within
the context of overall well-being and health. Begun in 1895 by Daniel David Palmer (18451913),
chiropractic holds that the body has its own ability to heal and maintain balance. According to chiropractic
theory, the nervous system is the center of all disease and healing. Traditionally chiropractors believed
that subluxation was often the root cause of disease. Currently chiropractors, who are licensed by the state
in which they practice, specialize in the manipulative treatment of the spine and joints, but they also
include dietary modification, nutritional supplementation, physical therapies, and exercise in their
treatments.

Practice Types

Fifty years ago most physicians who were not full-time members of hospital staffs worked by themselves
in an office, either in their home or in an office building. They paid their office expenses, taxes, and
liability insurance out of their income, and the difference was considered their "net income" from their
practice. As their practice got busier, their income increased. Currently many physicians work with other
physicians. Some of them have an ownership position in the practice or facility in which they work, but
others are employees and receive a salary from their employer. The following categories refer to the way
the office is structured, not the business arrangement or ownership.

Solo Practice

It is still possible for a physician to work in a solo practice, but to do so, he or she must make a number of
trade-offs. Solo practices are limited in their size by the number of patients one physician can manage.
When a physician practices alone, the medical assistant is usually responsible for aspects of both
administrative and clinical support.

Even if a solo practitioner employs an NP or a PA to see additional patients, the physician still must factor
into his or her workday some time to oversee the work of these nonphysician professionals. In addition,
the physician, as the employer, is usually responsible for paying the malpractice insurance premiums for
all of the licensed professionals in his or her office. Physicians in solo practice are also completely
responsible for their patients. Usually they make arrangements with other physicians to share after-hours
and weekend call responsibilities and to cover for vacations.
Group Practice

Currently many physicians participate in a group practice. The most common type of group practice
includes three or four physicians of the same medical specialty who band together to share resources such
as office space and personnel. In these groups, medical assistants usually specialize in either clinical or
administrative work, although they expect to help out in other areas.

Depending on the business form used, patients are the responsibility of either one physician or "the
group." In either case, if a patient's regular physician is not available, another physician in the office can
see the patient. In addition, physicians who work in group practices usually share after-hours and
weekend call responsibilities. They usually split the cost of malpractice insurance, and the policy is written
for the group rather than for each individual. Group practices are commonly owned by hospitals, and the
physicians and other providers are employees rather than owners.

Large medical groups with physicians who provide primary care, as well as physicians with other medical
specialties, are becoming increasingly common throughout the country. Their names often include the
words "associates" or "medical associates." This organizational form allows a sharing of resources that, in
turn, allows each physician in the group to provide a broader range of services. In the past, these groups
were more common in particular regions and in rural areas where a single group of physicians has the
responsibility of being both the physicians in town and the staff of a small, rural hospital. HMOs that
provide all services in one building, so-called "closed-panel HMOs," also operate as multispecialty groups.
These practices often have separate administrative departments for billing, appointment scheduling, and
referrals and separate clinical departments for phlebotomy, electrocardiography, laboratory work, and
radiography. In such practices, medical assisting jobs can be limited in scope, and specific responsibilities
depend on the department in which the medical assistant works.

Clinic

Traditionally a clinic was connected to a hospital and provided ambulatory care, often to patients with
limited financial resources. Patients were either seen at no charge or billed by the clinic, and physicians
were paid a salary for their services and/or saw patients as part of their residency program. Currently a
clinic usually refers to a public or nonprofit facility that provides outpatient public health services,
although private solo or group practices may use the word "clinic" in their name. Community health
centers, established by the federal government in the late 1960s, operate as clinics and have physicians
and NPs, PAs, and nurse-midwives all on salary.

Complementary and Alternative Medicine

Numerous other practices are used for the treatment of illness, some of which have a long tradition and
some of which have developed more recently. Studies from the early 1990s found that Americans
annually spend literally millions of dollars on therapies that are not part of their physician's standard
approach. Patients often do not even tell their physicians about these other treatments. When practices
have been used for extended periods in specific cultures, they may be
called traditional medicine. The term complementary medicine is usually used for medical treatments that
patients use in addition to standard medical treatments. The term alternative medicine refers to practices
that are used instead of standard medical treatment. For many patients, these may overlap. For example,
acupuncture has been a definitive method of treatment in traditional Chinese medicine for centuries (Fig.
1.5). In the United States it has become a popular treatment method used in addition to standard
treatment. It has become so popular that there are many schools to train practitioners, and the practice of
acupuncture requires a license in most states.

FIG. 1.5 Acupuncture involves the placement of several extremely thin needles in various parts of the body.
Since the early 1990s, scholars of medicine have begun to take an interest in studying complementary and
alternative practices scientifically. The federal government has since established the National Center for
Complementary and Integrative Health within the National Institutes of Health. This agency coordinates
and funds scientific research to study the effectiveness of these health practices. The most well-respected
medical journals such as the New England Journal of Medicine and JAMA have published a number of
studies about the effectiveness of various nonstandard therapies, and numerous specialized journals have
also been established to publish research about such therapies. When research demonstrates that a
practice is effective, physicians trained in the classic Western medical tradition are more accepting and
may even incorporate some of these practices or refer patients to practitioners.

What Would You Do? What Would You Not Do?

Case Study 3

While Aida is taking John Carter's medical history, he mentions that he has been getting acupuncture and
taking several herbal preparations that he buys at a health food store. He also says that he wears shoe
insoles with magnets in them because he has had heel pain for several months. He says, "You should try
them. They have really helped my heel pain." ■

What Would You Do? What Would You Not Do? Responses Case Study 1 What Did Aida Do?

□ Accepted Alicia Darwin's reason for changing medical offices without making a judgment.

□ Stated that she hopes Alicia will feel comfortable as a patient in their practice.

□ Stated that she is a medical assistant, not a nurse, and explained the difference briefly.

□ Clarified the legal position of a nurse practitioner in her state related to prescribing medications.
What Did Aida Not Do?

□ Agreed verbally or by implication that she is a nurse.

□ Asked for additional information about Alicia's previous physician or medical office.

□ Made any critical remarks about nurse practitioners or Alicia's previous physician.
□ Made any statement that could be interpreted as a guarantee that Alicia will like this physician better.

Case Study 2 What Did Aida Do?

□ Agreed that the condition of the break room could be improved.

□ Promised to talk to all staff members about keeping the break room clean.

□ Arranged time to speak to staff members either individually or as a group to discuss ways to keep the
break room clean and make a plan.
□ Encouraged all staff members to take an active part in developing a plan to keep the break room clean.
□ Followed up to be sure that any plan made was implemented and was effective.

What Did Aida Not Do?

□ Did not focus on identifying who was responsible when talking to either the physician or other staff
members.

□ Did not become defensive when talking to the physician or other staff members.

□ Did not single out any staff member(s) as responsible for the problem.

□ Did not complain about one staff member's behavior to any other staff member.
Case Study 3

What Did Aida Do?

□ Accepted John Carter's description of his complementary and alternative medical practices.

□ Documented all practices in the medical record.

□ Asked questions to explore the underlying problems such as heel pain or the reason for acupuncture.
What Did Aida Not Do?

□ Did not tell John that he might be endangering his health because of his use of complementary or
alternative medical practices.
□ Did not tell John that acupuncture, magnets, or herbs would not help him.

□ Did not ask John where to buy foot insoles with magnets.
□ Did not dismiss John's practices as insignificant and fail to document them. ■

Terminology Review

Key Term Word Parts Definition Ambulatory care ambulare: to walk

-ory: pertaining to

Medical care that is provided on an outpatient basis. The patient is able to come to the facility providing
care and return home after having received services.
Capitation A set payment provided by managed care insurance per patient per month
regardless of the amount of service the patient receives.
Curative treatment Treatment that cures disease.

Empirical

empiricus: experienced -al: pertaining to

Learned from observation or experiment.

Fee-for-service A means of payment for health care in which the cost for each service
provided is reimbursed in full or in part.
Formulary A list of prescription drugs covered or preferred by a managed care
insurance company.

Health insurance Purchase of protection for covered services related to health care.

Holistic

holos: whole

-ic: pertaining to

Considering the whole; in medicine, considering the entire person when providing health care.

Managed care A system that manages the delivery of health care with the intention of
controlling costs.
Palliative treatment Therapy that reduces the effects of a disease or condition but does
not remove the disease itself.
Patient-centered medical home (PCMH) A model of primary care that emphasizes patient-
centered health care based on a personal relationship among a patient, a physician, and the patient's care
team.
Quality assurance Measures to ensure that patients receive safe and appropriate
services.
Residency A program to provide training in a medical specialty to a physician who has
finished medical school.
Symptomatic treatment Therapy for symptoms of a disease or condition that does not
remove the disease itself.
Utilization review Assessment of medical services to determine whether they are
appropriate, necessary, and of high quality.
The Professional Medical Assistant

Abstract

This chapter describes the profession of medical assistants including characteristics, professionalism and
the role of medical assistants in the medical office. It describes various kinds of certification (since medical
assistants are usually not licensed.) It concludes with employment opportunities for medical assistants.

CHAPTER OUTLINE

INTRODUCTION TO PROFESSIONAL MEDICAL ASSISTING

EDUCATIONAL PROGRAMS FOR MEDICAL ASSISTANTS

CERTIFICATION FOR MEDICAL ASSISTANTS American

Association of Medical Assistants American Medical

Technologists California Certifying Board for Medical

Assistants National Healthcareer Association National

Center for Competency Testing Obtaining Additional

Credentials CHARACTERISTICS OF MEDICAL ASSISTANTS

Character Traits Personality Traits

Appearance

Initiative and Behavioral Skills PROFESSIONALISM

Professionalism for Medical Assistants Professionalism for Physicians PROFESSIONAL ORGANIZATIONS

Peer Support Continuing Education Legislative Advocacy Publications, Newsletters, and Websites ROLE

OF THE MEDICAL ASSISTANT Administrative Responsibilities Clinical Responsibilities Managing the

Medical Office Patient Education and Coaching Patient Navigation EMPLOYMENT OPPORTUNITIES

LEARNING OBJECTIVES/PROCEDURES

1. Describe the history of the medical assisting profession.

2. Explain how a medical assisting educational program becomes accredited.

3. Differentiate between various national credentials for medical assistants.

4. List character and personality traits of effective medical assistants.

5. Describe the appearance and behavior of a professional medical assistant.

6. Describe principles of effective time management.

7. Define professionalism for medical assistants and physicians.

Locate and define the legal scope of practice in own state.

8. Identify organizations and publications that guide professional behavior for medical assistants and
physicians.

9. Describe how professional organizations support the profession of medical assisting.

10. Identify the administrative tasks and clinical tasks performed by a medical assistant.

11. Discuss the medical assistant's role in the operation of the medical office and patient education.
12. List employment opportunities for medical assistants.

KEY TERMS

accreditation

continuing education unit (CEU)

fee splitting

health coaching

initiative

patient navigator

practicum

risk management

time management

Introduction to Professional Medical Assisting

Medical assisting came into existence as a career during the second half of the 20th century. Around the
middle of the 1900s, most physicians established their own practice when they completed their medical
education and hospital training. A physician (almost always a man) usually saw patients and had no
assistance, except possibly from his wife who answered the telephone and often did the billing.

The physician spent a large portion of each day making house calls. During a house call the physician
would examine a patient with only the equipment he could carry in his medical bag. The physician's office
was often located in a room in his house or the first floor of a building, with the physician living in an
apartment above. Patients who went to the physician's office may or may not have had an appointment.
They expected to wait to be seen.
In the first 20 years after World War II (before the increasing use of technology caused medical costs to
skyrocket), a physician usually charged $2 to $5, possibly $10, for an office visit, a sum that currently
seems small. However, for some patients, even this small charge was more than a day's pay. For physicians
the low fee was enough because the expenses of the practice were also low. In fact, physicians rarely
pressed poor patients for full payment. They always had many patients who owed them money, and it was
not uncommon for patients to pay small amounts on a weekly basis for many months or even years,
especially the parents of young children. Sometimes physicians would even barter by exchanging medical
care for goods or services provided by the patient. For example, a patient might pay for his medical care by
bringing the physician fresh produce from his farm.

During the past 70 years, the practice of medicine has changed dramatically. This, in turn, has changed the
way in which physicians operate their medical practices. With the advent of government insurance
programs, not only were office visits covered by insurance, but the medical office was also expected to
complete and submit the insurance forms to receive payment. Physicians soon discovered that the cost of
employing a person to complete these forms was offset by improved collections and cash flow. Gradually
almost all insurance billing shifted to the health care provider. As practices are consolidated, centralized
billing is common.

Advances in medical science made many more diagnostic tests, laboratory tests, and treatments
available and even necessary for good medical care. It made sense to have an assistant in the office to
perform these tests and allow the physician to concentrate on seeing patients.

Even as laboratory and diagnostic testing has increased in amount and in complexity, so too have the
administrative equipment and technology used in a physician's office. Currently there are computers,
wireless electronic devices, printers, fax machines, photocopiers, intercoms, and voicemail systems.

Physicians send claims to a number of different insurance companies. Many insurance plans require
prior approval for certain medical procedures, referrals to specialists, or surgical procedures. Insurance
companies and government programs prefer electronic claims filing and often make electronic payments
directly into physicians' office accounts at banks. This creates a need not only for more staff but also for
more highly trained staff.

Physicians have also almost completely stopped making house calls. Because of this, physicians need
more office space. In addition, patients with more complex needs are seen in physicians' offices rather
than in the hospital emergency department or outpatient department. Sometimes a patient must occupy
an examination or treatment room for an extended period of time, such as when an individual with
asthma is receiving an inhalation treatment.

Another change that has had an impact on the medical practice involves the increase in medical
litigation. Since the 1970s, physicians have practiced what has come to be called "defensive medicine."
Because of the fear of a malpractice lawsuit and the high cost of malpractice insurance,
physicians began to perform more laboratory and diagnostic tests to rule out even the most unlikely
cause of an illness. Another factor stimulating the expanded use of laboratory tests in outpatient care is
the increased number of Clinical Laboratory Improvement Amendments (CLIA)-waived tests that are
available.

As services expanded, physicians employed nurses to help them in their offices. This helped ease their
burden of performing procedures and caring for patients, but nurses were often unable and unwilling to
assist with the administrative aspects of the practice. As a result, many physicians found a willing
candidate and trained that person to assist first with administrative duties and then with both patient care
and administrative duties. This evolved over time into what is currently the medical assistant profession.

In 1956, medical assistants from 15 states organized to form the American Association of Medical
Assistants (AAMA). In 1978 the profession was recognized by the U.S. Department of Education. The
AAMA and other organizations, especially the American Medical Technologists (AMT), have worked to
define professional training for the medical assistant and to provide certification for medical assistants
through national examinations.

Educational Programs for Medical Assistants

Initially, medical assistants received on-the-job training, but as the profession grew, formal educational
programs were established. These programs vary in length from 6 months to 2 years. Medical assisting
programs include theoretical and practical preparation in all aspects of the medical assisting profession.
To maintain quality, many of these programs seek accreditation, credit, or recognition from a regional or
national organization for maintaining certain standards. The two recognized accrediting agencies for
medical assisting programs are the Commission on Accreditation of Allied Health Education Programs
(CAAHEP), in collaboration with the AAMA, and the Accrediting Bureau of Health Education Schools
(ABHES). It is important to distinguish program accreditation from institutional accreditation. There are
many medical assisting programs in accredited institutions of higher learning that have not obtained
specific program accreditation.
A medical assisting program seeking accreditation from one of the aforementioned agencies must prepare
a written report showing how the educational standards of that agency are being met. After the report has
been submitted, an accreditation visit is made to validate the information presented in the report. Once
accreditation has been granted, graduates of the program are eligible to take either the certified medical
assistant (CMA) AAMA or registered medical assistant (RMA) certification examination. Accredited
programs must include at least 160 hours of practical work experience in a medical office or clinic, known
as a practicum or practical experience (formerly called an externship).

Certification for Medical Assistants

Medical assistants usually graduate from an educational program that may vary in length from 6 months
to 2 years. If the medical assistant graduates from a program accredited by CAAHEP or ABHES, he or she
is automatically eligible to take a national certification examination. Certification is a process by which an
organization, often a national body, validates the credentials of an individual
or a program. Certification is important for health care professionals. Professionals such as physicians and
nurses require certification (by passing a national examination) as a condition for obtaining a state license
to practice their profession. Certification is also important for medical assistants, especially those who live
in a state that does not regulate unlicensed health professionals. When an unbiased national organization
validates knowledge and skills, the employer can be sure that the medical assistant has excellent
qualifications.

Several organizations provide certification for medical assistants. Each has different requirements for
eligibility, and some organizations offer more than one certification. In many areas, employers hire only
medical assistants who have passed a certification examination. As medical assistants perform more
specialized clinical tasks, employers have become increasingly concerned about validating skills and
knowledge before hiring them.

American Association of Medical Assistants

The AAMA administers the CMA (AAMA) examination. To take the examination, an individual must
have graduated from a medical assisting program accredited by CAAHEP or ABHES or be a CMA
(AAMA) recertificant.

The examination is computer based and is administered online at testing centers. Most states have
several testing locations.

Application materials can be obtained from the AAMA Certification Department, 20 North Wacker Dr.,
Suite 1565, Chicago, IL 60606-2903; from the director of accreditation at the medical assisting program
attended; or a medical assistant can apply online at the AAMA website (www.aama-ntl.org).

Passing this examination allows a medical assistant to use the title CMA (AAMA) after his or her
name on all official documents, including patient records and business cards.

American Medical Technologists

The AMT is an organization that offers several certifications. Medical assistants may take an examination
to be certified as an RMA, a certified medical administrative specialist (CMAS), and/or a registered
phlebotomy technician (RPT). In addition, this organization certifies medical technologists and medical
laboratory technicians.

To take the RMA examination, an individual must have (1) graduated from a medical assisting program
that includes at least 720 hours of training in an institution that is accredited by an organization
approved by the U.S. Department of Education; (2) graduated from a formal medical services program of
the U.S. Armed Forces; (3) been employed full-time in the profession of medical
assisting for at least 5 of the previous 7 years; or (4) been instructing in an accredited MA program for
between 1 and 5 years.

Applications for the RMA examination can be obtained from the Registrar's Office, AMT, 10700 W.
Higgins, Suite 150, Rosemont, IL 60018, or the applicant can apply online. Information about the
examination can be obtained from the AMT website (www.americanmedtech.org). The RMA
examination may be given at a student's school, or an applicant may take the test online at testing
centers located throughout the country.

Passing this examination entitles the medical assistant to use the initials RMA after his or her name on
all official documents.

California Certifying Board for Medical Assistants

The California Certifying Board for Medical Assistants (CCBMA) is one of the three organizations
recognized by the Medical Board of California for certification of medical assistants (with the AAMA and
the AMT). The CCBMA administers the California CMA examination which is primarily taken by residents
of California. Information is available on the CCBMA website at www.ccbma.org.

National Healthcareer Association

The National Healthcareer Association (NHA) offers certifications for several allied health professions.
Medical assistants may be interested in obtaining certification as a certified clinical medical assistant
(CCMA), certified medical administrative assistant (CMAA), certified electrocardiogram (ECG) technician
(CET), and/or certified phlebotomy technician (CPT). The NHA also certifies administrative medical
assistants, billing and coding specialists, and other health professions. Information is available on the NHA
website at www.nhanow.com.

National Center for Competency Testing

The National Center for Competency Testing (NCCT) offers testing for graduates of affiliated programs, as
well as medical assistants with experience or training through the military. It is possible to become
certified as a medical assistant (NCMA), a medical office assistant (NCMOA), an ECG technician (NCET),
and/or a phlebotomy technician (NCPT). The NCCT also certifies insurance and coding specialists and
other health professions. Information is available on the NCCT website at www.ncctinc.com.

Obtaining Additional Credentials

A medical assistant may need to validate other skills as a condition of employment.

Training in cardiopulmonary resuscitation (CPR) is offered directly through the American Red Cross
(ARC) and the American Heart Association (AHA) and by hospitals and other health care agencies. Like
other health professionals, medical assistants recertify at the health care provider level every 2 years to
be sure their skills are current as required by their professional organization and/or employer. Most
health care facilities require current CPR credentials.

Medical assistants may also take courses in performing first aid, hearing tests, limited x-ray
examinations, or other specialized tests, depending on state law and the needs of the medical
practice. In many areas, medical assisting certification or registration is a valid qualification to
perform phlebotomy, but some states and/or institutions require separate certification in
phlebotomy. This can be obtained through organizations listed earlier, as well as the American
Society for Clinical Pathology (ASCP) or the American Society of Phlebotomy Technicians. The
websites of these organizations are listed at the end of the chapter.

A medical assistant who obtains experience working for a podiatrist or an ophthalmologist may want to
obtain certification as a podiatric medical assistant, certified (PMAC) or a certified ophthalmic assistant
(COA) or technician (COT).

If the medical assistant has specialized in the administrative area, additional credentials can be obtained
as a medical administrative specialist. It is also possible to obtain one of the various certifications in
medical billing and/or coding with additional education, such as a certified professional coder (CPC)
from the AAPC, an organization that specializes in coding training and certification. A medical assistant
might also obtain certification as a certified coding associate (CCA), a certified coding specialist (CCS), or
a certified coding specialist-physician-based (CCS-P) from the American Health Information Management
Association (AHIMA).

Characteristics of Medical Assistants

Medical assistants possess or develop a number of characteristics that make them effective in their work.
Although a person's character and personality have been shaped by heredity and environment, a medical
assisting student can work to enhance the traits that are important for health care delivery. Appearance
and behavior are also an important means of projecting competence in the medical office (Fig. 2.1).

FIG. 2.1 A professional appearance projects competence and increases the patient's confidence in the
medical assistant.
Character Traits

The most important character traits of a competent medical assistant are dependability, honesty, and
tolerance. Character is closely related to the moral and ethical values of an individual. It is often regarded
as the true self and reveals itself through actions over time. As an integral part of the office
practice, for example, medical assistants must arrive at work on time and not take days off except
when ill or if a family emergency arises. Medical assistants who come to work promptly every day
demonstrate that dependability is part of their character.

A medical assistant projects honesty by working within his or her "scope of practice"—that is, doing only
what he or she is trained to do and being comfortable in saying "I don't know" or "I don't know how to"
when appropriate. State laws regulating the scope of practice for medical assistants vary greatly, so it is
important always to be aware of legal restrictions (Procedure 2.1). Medical assistants must always
maintain confidentiality and behave ethically. They must recognize that a high level of trust is an
important component of high-quality patient care. Tolerance or a willingness to accept the beliefs and
practices of others is another important character trait. Tolerance allows medical assistants to work
effectively with coworkers and patients from a variety of religious, ethnic, and cultural backgrounds. The
patient-centered medical home in primary care emphasizes seeing each patient as a whole person and
responding to needs throughout the life span.

Putting It All Into Practice

My name is Beth Ann Wilson, and I am a certified medical assistant. I attended a medical assisting training
program at the community college near my home. I was the first person in my family to go to college, and
my family was very proud of me. After the first year (two semesters), I received a certificate in medical
assisting, and I found a job in our town at a group practice specializing in obstetrics and gynecology. My
instructor encouraged me to take the CMA (AAMA) examination, and I was glad when I found out that I had
passed it. I continued to take night classes so that I could get my associate's degree. I also attend the state
and local chapter meetings of the AAMA so that I can get the contact hours I need to renew my CMA
(AAMA) certification.

When I started working, I spent most of my time at the front desk answering the telephone and checking
patients in, but after about 8 months I began to escort patients back to the examination rooms, prepare
them for examinations, perform laboratory tests, and assist during examinations. We do some specialized
tests in our office, including colposcopy, and I was trained to set up for the test and assist the physicians.
Janice, our office manager, who is also a CMA (AAMA), has asked me to be responsible for ordering all the
supplies for the office and taking inventory. She has also encouraged me to take business courses and
attend seminars related to using the electronic medical record which we implemented a few years ago.
Not too long ago, Janice told me that she is planning to cut back her hours in the spring, and she hopes that
I will be able to take over some of her duties in running the practice. That will be a big challenge, but I
think I am ready for it. I have a few ideas of my own, and I will be glad for an opportunity to try them out.
■

Personality Traits
Certain personality traits are essential to being a successful medical assistant. Personality is closely related
to character, but it refers more to the outward way that a person acts with others. Personality traits
include being genuinely interested in helping people; being outgoing, warm, and caring; and having a sense
of humor. The ability to remain calm in challenging or difficult situations is also important.

The practice of medicine is one of the "caring professions." Each professional in the medical office needs to
have a serious interest in helping people and be able to communicate that when interacting with others.
Although the medical assistant must know how to perform the necessary administrative activities
effectively and efficiently, the first priority is the care of patients who visit the office.

The concepts of warmth and caring are discussed in more detail in Chapter 4 in the section on
communication. For now, it is important to say that being able to interact in a caring manner is a valuable
personality trait. Some aspects of caring can be learned and practiced. If an individual does not have a
naturally caring personality, he or she will find it much harder to learn the communication skills needed to
express caring.

The ability to put the needs of others first is important. The medical assistant must not allow personal
circumstances to interfere with interactions with patients, colleagues, or physicians. Remaining
objective and concentrating on the situation at hand are important. The patient's needs take precedence
over the needs of the medical assistant.

The atmosphere in a medical office may change quickly from calm and orderly to rushed and somewhat
disorganized. The medical assistant who can remain calm when things do not go as planned will be more
successful than one who is thrown completely off balance by sudden changes in schedule or plans and
who becomes emotionally unable to respond effectively.

What Would You Do? What Would You Not Do?

Case Study 1

It is a busy Monday and Beth Ann is getting ready to leave the office for her lunch break at 1:30 p.m. when
a male physician steps out of an examination room and asks her to assist him with a Pap test and pelvic
examination. Beth Ann knows that it is office policy to always have a female staff member in the
examination room when a pelvic examination is done. She tells the physician that she is about to go for
lunch, but she will find someone to assist him. She goes to the front and finds the receptionist at the desk
checking in patients, but neither of the two other medical assistants working that day is in sight. ■
Appearance

Personal appearance influences both the feelings and the behavior of the medical assistant. It also
influences the way in which the patients respond to the medical assistant. Psychologists have long
recognized the importance of physical appearance. Important judgments are made within seconds of
meeting a stranger on the basis of appearance and body language.

When the medical assistant calls a patient to come from the waiting room to the examination or treatment
room, the patient immediately forms an impression of the quality of care the medical assistant—and the
physician—are going to provide (Fig. 2.2). A medical assistant who is neat, clean, and well-groomed
projects a sense of professionalism, authority, and competence. When medical assistants are courteous,
they project respect for a person's dignity. This is important because many patients feel awkward,
especially when dressed in underwear and an examination gown. In the same way, anything that the
patient experiences as negative can result in an instant feeling of doubt in the medical assistant's ability.
This may be generalized to a general feeling of doubt about all office staff. Patients often react negatively
to rumpled clothing, dirty or worn shoes, unpleasant body odor, strong scent from perfume or personal
products, piercings, tattoos, or an appearance that seems too "dressed up" because of jewelry, false nails,
heavy makeup, and/or elaborate hairstyle.

FIG. 2.2 The patient judges the medical assistant's professionalism when called from the waiting room.
Most medical offices require that medical assistants wear a uniform when performing clinical tasks. The
uniform worn by most medical assistants consists of scrub pants with a scrub top or shortsleeved shirt;
clean, white, soft-soled shoes; and a laboratory coat or jacket as needed. The top and/or jacket may be
patterned, especially in a pediatric practice. Both top and bottom should fit well without being too tight.
Pants should be hemmed neatly so that they do not drag on the ground. In some practices all staff wear
coordinated uniforms. When performing administrative tasks, the medical assistant wears scrubs or street
clothes. If street clothes are worn, they should project a businesslike appearance (Fig. 2.3). For example,
jeans are always unacceptable attire in the medical office.

FIG. 2.3 Street clothes may be worn for administrative tasks in some offices.

Neatness and good grooming are also important for health and safety reasons. Hair carries bacteria, even
if regularly washed. Medical assistants who perform clinical activities should pull their hair back and tie it,
usually in a ponytail. A little bit of makeup can enhance a female medical assistant's professional image,
but too much is not appropriate for a work environment. Both female and male medical assistants should
always present a businesslike appearance.
Medical assistants should maintain scrupulous personal hygiene and avoid perfume or scented personal
care products. Many patients have allergies or respiratory problems that can be aggravated by perfumes,
colognes, and scented hairspray or deodorants.

Nails should be kept relatively short and should not be polished. Long nails are not functional for
keyboard work, patient care, or laboratory procedures. The Centers for Disease Control and
Prevention (CDC) recommends that artificial nails not be worn and fingernails be kept inch or shorter
when one is caring for patients at high risk of acquiring infections.

Traditionally, health professionals were allowed to wear only "functional" jewelry—a wristwatch and a
plain wedding band—because jewelry is not regularly washed and can become tangled in equipment.
Currently, most medical offices allow staff to wear small earrings that do not dangle below the earlobe
and necklaces that can be tucked into the shirtfront. Wearing rings other than a wedding band is not a
good idea. Rings can cut through protective gloves or scrape a patient. In addition, they need to be taken
off frequently for handwashing. Most medical offices do not allow visible piercings or implants, except for
the ears. It may also be a policy of the medical office that visible tattoos and implants (microdermal or
subdermal) must be covered. Those on the arms can be covered with a long-sleeved jersey worn under
the scrub top or special sleeves designed specifically to cover tattoos or implants.

Initiative and Behavioral Skills

Initiative is the ability to begin or follow through on a plan without being supervised. Initiative is an
important quality for a medical assistant. The willingness to take initiative and perform tasks that need to
be done without being specifically instructed to do so improves the functioning of the office as a whole.

However, initiative does not mean taking over. The office is the physician's place of business, and the
physician expects to run it. Initiative does not mean redecorating the waiting room without asking
permission. It does mean doing things that need to be done without being asked, keeping up with current
issues in practice without being told, and identifying helpful educational opportunities and asking
permission to attend. It also means finding useful things to do when the office is slow, such as restocking
supplies, ordering supplies, and cleaning out cabinets and cupboards.

Office managers who supervise medical assisting students during externships relay that some medical
assisting students do not take enough initiative. Taking appropriate initiative is an important skill to
develop. While in school, students learn to wait for someone to tell them exactly what to do and how to do
it. In the workplace the opposite quality is valued. A medical assistant is expected to figure out what needs
to be done and how to help out—even during a practicum.

When a medical assistant begins a practicum or a new position, he or she must learn when to jump in
and perform a task without being asked. The task that is most comfortable for the medical
assistant to perform may not be the one that shows the most initiative. Medical assisting students can
make an independent decision to restock examination rooms or clean the break room if they have no
other pressing duties.

Initiative is a quality that employers look for in new medical assistants. An employer may even test a new
employee's initiative by showing him or her how to do something, such as restocking an examination
room at the end of the day and then watching to see if the new medical assistant restocks the examination
room without being told.

Managing activities, tasks, and schedules efficiently requires attention and effort first as a student and
later as a professional medical assistant. This concept of time management goes beyond day-today use of
time to include planning, setting goals, prioritizing, and analyzing the effectiveness of how time has been
used.

Getting organized requires a method to keep track of personal, class, and/or work schedules. An effective
schedule includes classes, work schedules, meetings, and/or other regular activities, but it can also be
helpful to schedule time for specific tasks such as homework (for a student) or preparing an inventory
(for a working medical assistant). There is a tendency to put off tasks that seem difficult or unappealing.
Scheduling specific times to work on these types of tasks increases the likelihood of completing them so
that they are done well and on time.

For class and work activities, it may be helpful to create and update a task list. In its simplest form, this is
created daily as a list of tasks to be done; each task is checked off or crossed off when it is completed. Task
lists do not have to be limited to a single day, and they can be prioritized with the tasks placed in order
from most important to least important. In analyzing a schedule, some unimportant activities may stand
out as items that can be eliminated or reduced in frequency. It may provide a psychological boost to limit
the task list to tasks that can really be completed within the allotted time span.

To perform many tasks efficiently, it is important to have easy access to information including names,
addresses, and telephone numbers of friends, classmates, or business contacts. Reference materials
needed for the job or for schoolwork should also be easily accessible.

There are many tools to facilitate effective use of time, including a personal organizer, or personal
planning book, or scheduling and information management software on a smartphone or computer.
Address books and reference materials can also be in book or index card format or electronic format.

The willingness to adapt to change is important for medical assistants, as well as all health care workers.
The pace of change within ambulatory care is fairly rapid, so it is unwise to become attached to one way
of doing things. Changes in equipment, procedures, staff, and setting can occur
quite frequently, but patient care needs to remain excellent. When the medical assistant approaches
changes with tolerance and even enthusiasm, the office runs more smoothly. The medical assistant needs
to adapt to the office setting rather than expecting the office to adapt to his or her preferences.

Finally, it is important for the medical assistant to work well with others and be a team player. Behavior
that enhances patient care includes helping others, maintaining a positive attitude and not complaining,
avoiding gossip, working within the established chain of command, and handling stress without losing
emotional control or creating emotional scenes. Keeping perspective, accepting corrections or criticism
without becoming defensive, and learning from mistakes are important. These behaviors facilitate
working with others over the long term with a minimum of discord.

What Would You Do? What Would You Not Do?

Case Study 2

Dawn Elliot, a 48-year-old woman, brings her mother, Ruth Mitchell, who is 70 years old, to the office with
complaints of vaginal bleeding. The physician asks for blood to be drawn in the office to determine if Mrs.
Mitchell has anemia from blood loss. Diane, a medical assisting practicum student who has been working
with Mrs. Mitchell, comes to Beth Ann and says, "Can you draw the blood from my patient? She says she
doesn't want a student to draw her blood." ■

Professionalism

Professionalism is behavior based on a body of knowledge and ethical standards to serve the public. The
particular body of knowledge is different for each profession, but ethical standards for professionals are
similar.

Professionalism for Medical Assistants

The AAMA maintains a code of ethics for medical assistants, and the AMT also maintains a set of
standards that define professional practice. These codes of ethics can be viewed at the websites of each
organization.

The medical assistant's ethical responsibilities are to admit mistakes, stay within his or her training and
legal scope of practice, maintain confidentiality, stay current, and uphold the honor of the profession.
This may mean having to confront a coworker who is not adhering to such principles.

Dealing with a coworker's inappropriate conduct is difficult, especially for a new employee or if the
coworker is higher in the organizational hierarchy. We live in a society that does not like "tattletales.
On the other hand, unprofessional behavior in a medical office is disruptive to the concept of teamwork.
Even if the unprofessional behavior does not pose an immediate threat to a patient, any behavior that
results in people not working well together can lead to an uncomfortable or dangerous situation. The
medical assistant should first discuss the situation with the coworker by calmly and objectively describing
the actions or behavior that he or she considers unprofessional. If the person does not correct the
situation, it is appropriate to report the behavior to the office manager. If the behavior of a coworker is
illegal or threatens the health or safety of others, the medical assistant should report it as soon as possible
to the individual's supervisor. Larger institutions often have a safety hotline where both patients and staff
can report concerns anonymously. States maintain websites where complaints can be filed if health care
professionals are believed to have performed illegal or unethical activities.

What Would You Do? What Would You Not Do?

Case Study 3

Before examining Ruth Mitchell, the physician asks Beth Ann to recheck Mrs. Mitchell's blood pressure. It
is 190/100 in the right arm and 186/98 in the left arm. Beth Ann notices that the blood pressure had been
taken that day by Diane, a medical assisting practicum student, who had recorded it as 130/80. Beth Ann
asks Diane if she is confident about the blood pressure reading she obtained from Mrs. Mitchell. Diane
says, "It was really faint, and I didn't hear it that well, so I wrote down the same blood pressure as she had
the last time she was here. I didn't want to look incompetent. Besides, I was afraid it might affect my grade
if you thought I was having trouble hearing the blood pressure." ■

Professionalism for Physicians

For physicians, professionalism means treating patients based on the body of scientific knowledge the
physicians have accumulated, and continue to accumulate, over their working lifetime. In addition,
physicians are bound by both ethical standards and legal regulations.

One source of guidance for physicians is the American Medical Association's (AMA's) Principles of
Medical Ethics. The AMA code of ethics is reviewed and updated periodically by that organization.

Other sources of professional guidance for physicians include the following:

State and federal regulations

Regulations of the hospital(s) to which the physicians admit patients

• Any open-panel health maintenance organizations or preferred provider organizations in which the
physicians participate
• The national medical board of their specialty or subspecialty

Physicians may have traditionally taken guidance from Hippocrates (c. 460-377 BCE). Hippocrates was an
ancient Greek physician who wrote the Hippocratic Oath. The Hippocratic Oath served as a guide to good
conduct for ancient physicians, and parts of it are still currently applicable. Its philosophic underpinnings
are still taught in medical school and adhered to by physicians, especially the key concept: "First, do no
harm."

For more information on unprofessional activities of physicians, and by extension all office staff, see
Highlight on Unprofessional Conduct for a Physician.

Highlight on Unprofessional Conduct for a Physician

Even if they are not illegal, many activities are considered unprofessional for physicians, and by
extension for their employees, including the following:

• Receiving payment for referrals to other physicians, laboratories, treatment centers, or pharmacies.
Although physicians often make specific referrals, it is unethical for them to have arrangements to receive
payments for those referrals, and especially to refuse to refer a patient unless a payment is made. This
practice is sometimes called fee splitting. It is also unethical to charge a patient simply for being admitted
to a hospital, without any other service being provided.
• Prescribing medication or diagnostic tests for financial gain rather than because of the patient's need
for the test.
• Pressuring patients to use pharmacies or laboratories in which the physician has a financial interest. It
is also unethical to prescribe medication, tests, or procedures that are not medically necessary. Billing an
insurance company for unnecessary procedures is illegal.
• Accepting gifts from pharmaceutical companies or medical equipment manufacturers or suppliers in
return for promoting the company's product or prescribing only the company's drug. Physicians may
accept inexpensive or educational gifts if allowed by state law with the understanding that they have no
obligation to promote the product.
• Allowing another physician or surgeon to perform surgery without informing the patient. The patient
has the right to know who is performing a procedure.
• Failing to disclose the source of sperm used for artificial insemination (e.g., husband, sperm bank, paid
donor). The physician may not substitute sperm without informing the patient.
• Failing to practice medicine appropriately.

• Practicing medicine under the influence of mind-altering drugs, alcohol, or any prescription medication
that may impair mental function, alertness, or physical performance.
• Allowing an unlicensed person to practice medicine.

• Failing to order a consultation regarding any medical problem that is beyond a physician's personal
experience and expertise. For example, a gynecologist should not treat a patient for renal failure.
• Withholding information about a patient's medical care from another medical facility just because the
patient has an outstanding bill.
• Putting a patient at risk of human immunodeficiency virus (HIV) infection, or refusing to treat a patient
who is HIV positive.
• Performing a procedure that might transmit HIV to a patient if a physician or any other health care
worker is HIV positive.
• Engaging in a sexual relationship with a patient. Something inherent in the relationship between two
individuals in which one is perceived to be more influential than the other puts pressure on the "weaker"
party to please the more powerful party. Because this makes it difficult to determine if consent is freely
given, such a relationship should never be sexual in nature. Sexual relationships between professionals
and the people they serve (e.g., physician-patient, attorney-client, teacher-student) are thus considered
unethical and unprofessional. ■
Professional Organizations

The AAMA and the AMT are professional organizations for medical assistants. For an annual membership
fee, many benefits are available. Medical assisting students can join either the AAMA or the AMT for a
reduced annual rate and receive member services. Membership information is available at the website for
each organization.

Peer Support

Through local and national meetings and workshops, medical assistants are able to enter a network of
peers with whom they can share and from whom they can learn. They can also obtain insurance at
reasonable cost, professional journals, and access to other sources of information important to the
profession.

Continuing Education

With the constant change in the medical field, it is not merely important but necessary to keep skills up to
date, attain new skills, and obtain new information about professional practices. Most health professions
require a certain amount of continuing education for licensure or certification renewal. These are
designed either as contact hours or continuing education units (CEUs). A CEU is a unit of participation in
professional continuing education.

Medical assisting contact hours and CEUs can be obtained from educational programs that have been
approved by the particular certifying agency. The AAMA validates continuing education programs given
through the state and national organization. Attending meetings of professional organizations is the best
way to find educational programs specifically for the needs of professional medical assistants. Home study
programs are also available to obtain continuing education credit.
An individual must be recertified as a CMA (AAMA) every 5 years. This can be accomplished by retaking
the certification examination or by successfully completing the required continuing education programs.
Sixty points must be accumulated during the 5-year period: 10 in the administrative area, 10 in the clinical
area, and 10 in the general area, with 30 additional hours in any of the three categories. Of these, 30 points
must be CEUs (1 contact hour each) from AAMA-approved programs.

If certified after January 2006, RMAs must accumulate 30 points of continuing education every 3 years.
(One contact hour is equivalent to one point.) Those who were certified before this date are expected to
keep up to date with current practice, but there are no specific continuing education requirements
beyond payment of the annual fee. Medical assistants who become certified through other organizations
must meet their requirements for recertification.

Legislative Advocacy

One of the tasks of professional organizations is to monitor legislative initiatives at the state and
national levels that may affect the profession. For example, the AAMA petitioned the CMS to designate
medical assistants with a national certification as qualified for computerized physician order entry
(CPOE) for Stage 2 of Meaningful Use of the electronic health record. This was allowed, and the wording
of the CMS Stage 2 Final Rule was updated.

Publications, Newsletters, and Websites

Both the national and the state organizations provide a means for communication among professional
medical assistants, including CMA Today, published by the AAMA, and the Journal of Continuing
Education Topics and Issues, published by the AMT. The national organizations have state associations,
often with several chapters within the state. The state organizations may produce newsletters and
maintain websites. Conferences are held annually both nationally and at the state level to enhance
communication and contact among members of the profession.

Role of the Medical Assistant Administrative Responsibilities

Various administrative responsibilities must be performed on a daily basis in a medical office. We like to
think of a physician's office as a place where patients receive medical treatment, but in reality much of the
activity in a physician's office involves managing the logistics of scheduling patients, preparing to provide
services, and receiving payment for services. The medical assistant may be responsible for a number of
these activities, although larger offices may employ specialists to perform these tasks.
1. Scheduling appointments, both over the telephone and in person, is a primary responsibility of the
medical assistant. A patient may also need to have appointments made with other medical facilities;
examples include a consultation with a specialist, a diagnostic procedure, outpatient surgery, continuing
therapy or rehabilitation, and a hospital admission. Some patients may need to schedule multiple
appointments with other facilities as the result of a single office visit. The medical assistant must learn the
procedure for making and documenting each type of appointment.
2. Maintaining the medical record and filing records and reports have traditionally been some of the
medical assistant's roles. With the increasing use of electronic medical records, there is less manual filing
in many offices, but it still may be necessary to scan paper reports and keep track of laboratory and
diagnostic test results. Each patient encounter with a clinician-physician, nurse practitioner (NP), or
physician assistant (PA)-is followed by documentation of the patient's visit. Clinicians may enter
information directly into an electronic medical record, or they may create handwritten or dictated patient
notes. If the dictation method is used, it may be transcribed using voice recognition software or it may be
sent to an outside service electronically. In this case the medical assistant prints the reports after they
have been returned and files them after the physician has approved them. The medical assistant may
prepare letters and other documents for the physician. Patients often receive printed summaries of their
visit before leaving the office.
3. Every patient visit generates activities that are necessary for the physician to be paid for the services
provided. The medical assistant must know how to accept and document payments, total and enter
charges, code the procedures and/or diagnostic tests performed, and enter payments received. These
charges and payments are entered into the office computer to keep track of money owed to and received
by the practice. In turn, the charges are used to generate insurance claims and patient bills. In larger offices
and clinics, a separate business office usually handles financial matters. Small offices often send billing
information to an outside billing service. If billing is performed in the office, the medical assistant must be
able to create patient bills and submit insurance claims.
4. On a regular basis, checks and cash need to be deposited into the office's bank account. Preparing bank
deposits and recording the deposits in the office's checkbook are activities that medical assistants often
perform.
5. Every business has bills to pay. These include rent (or mortgage, if the office is owned), electricity,
lease payments on equipment, staff salaries, and a number of other regular payments, such as liability and
malpractice insurance. Medical assistants or business office personnel usually pay these bills and maintain
records of these and other bills owed by the office. (Some offices have an outside bookkeeping service
perform these tasks. Even in offices that pay their own regular bills, salary may be managed by an outside
payroll service.)
6. In the patient-centered medical home, the medical assistant may have additional administrative
responsibilities to enter health registry data into the medical record and to monitor patient progress by
the use of disease-specific registries and tools. Previsit administrative tasks may be more extensive than in
other types of medical practices.
Clinical Responsibilities

Depending on the type of medical office, clinical activities may make up the bulk of the medical assistant's
responsibilities. The medical assistant prepares patients for examination, performs diagnostic tests,
performs treatments, and assists the physician with examination and treatment.
1. Medical assistants are often asked to collect and process specimens. Some specimens are tested in the
office, and others are sent to an outside laboratory.
2. Medical assistants perform several diagnostic tests, such as ECGs and respiratory testing.

3. Medical assistants prepare patients for examination, including taking medical histories, weighing the
patient, measuring vital signs, and obtaining information about allergies, current medications, and the
chief complaint. Having this done by a medical assistant may allow the physician to see at least one extra
patient per hour.
4. After each patient appointment, the medical assistant prepares the examination and/or treatment
room for the next patient (Fig. 2.4). This involves making sure that there is fresh paper on the table, the
proper instruments and supplies are available for the next examination or procedure, and the necessary
equipment is available and in working order.

FIG. 2.4 Medical assistant preparing an examination room.

5. Medical assistants help the physician with examinations and procedures. The medical assistant settles
a patient into an examination room and positions and drapes the patient for portions of the examination.
Another duty is to pass instruments and supplies to the physician during procedures. The medical
assistant may also remove sutures and change sterile dressings. If minor surgery or sterile procedures are
performed in the office, the medical assistant sets up the equipment and supplies and then assists the
physician as needed.
6. Medical assistants may perform treatments, including nebulizer treatments and application of hot and
cold packs or compresses.
7. Medical assistants prepare and administer medications and immunizations depending on state law
and office policy. The administration of medication requires concentration and precision. All medications
must be documented according to office procedure.
8. Sometimes a medical assistant also has to perform emergency care and administer first aid or assist
with an office emergency. This does not happen often, but every medical assistant must be prepared.
Managing the Medical Office

The medical assistant may have many responsibilities to keep the medical office running smoothly.

1. Operational activities involve maintaining the inventory of supplies. This can include everything from
purchasing tongue blades and gauze to contracting with a uniform service to launder the staff's laboratory
coats or patient gowns. It may also involve evaluating and recommending changes in the supplies
purchased and evaluating new equipment for potential purchase or lease.
2. A second group of activities involves personnel policy and procedures. Businesses are always
reviewing their policies and procedures and updating and revising them as needed. As offices move from
one or two physicians and a small staff to a larger organization, policies and procedures become more
important to standardize the way all employees are dealt with.
3. Risk management is the development of policies and procedures that minimize the chances of the
practice being sued by a patient or disciplined by a regulatory agency. Every physician's office needs to
have one person responsible for risk management, which involves, among other areas, the promotion of
health and safety for office personnel and patients, implementation of a quality assurance program,
maintenance of proper infection control measures, fire prevention, and the proper disposal of hazardous
waste and controlled substances.
4. Record keeping is an important activity for the individual who manages a medical office. In addition to
patient records, many other kinds of records must be kept, including office insurance records, quality
assurance records, maintenance contracts, personnel records, and financial records.
Patient Education and Coaching

Instructing and coaching patients are important roles for medical assistants. The medical assistant
instructs the patient in several types of situations.

1. The medical assistant is often responsible for educating the patient about office procedures, including
giving information to a new patient who is making the first appointment, as well as instructing an
established patient whose circumstances have changed.
2. The medical assistant may provide information about maintaining health to patients directly as
directed by the physician or by making educational materials available in the office. These are always
reviewed by the physician before being given to patients (Fig. 2.5).

FIG. 2.5 The medical assistant uses brochures to teach a patient.

3. The medical assistant may teach a patient about ways to manage his or her disease or condition,
especially if the patient is newly diagnosed. For example, a physician might ask a medical assistant to teach
a patient how to take his or her own blood pressure using a sphygmomanometer and a stethoscope and
keep a record of the results.
Maintaining the highest possible level of health requires more than knowledge. Patients must be motivated
to make healthy choices to maintain their current level of health, as well as to prevent disease and comply
with treatment plans prescribed by the physician. Health coaching is defined as a process that helps
patients to identify their values related to health, set health goals, and take steps to meet their personal
goals. Coaching requires listening to patients, validating their concerns, and also encouraging them to
make the changes that their own beliefs tell them are important. Medical assistants can work with patients
to help them maintain health through proper diet, exercise and rest, and social interaction. They can also
assist patients, especially those with risk factors, to take positive steps to prevent disease by identifying a
specific target (e.g., a lower cholesterol or low-density lipoprotein [LDL] level), setting goals to meet that
target, and following up with the necessary behavior changes. Health coaching can also be an effective way
to help a patient stick to a prescribed treatment plan. If the physician has prescribed a regimen of home
glucose testing, insulin, and dietary modifications, a medical assistant might coach the patient to improve
compliance after initial teaching has been completed. If a patient needs services from the community, the
medical assistant may provide brochures from community agencies or locate community resources for a
patient-such as an exercise class given without cost at a center for senior citizens-but it might also be
necessary
to coach the patient to make specific plans to use those services. A patient might also require coaching to
adapt to decreased balance or strength by avoiding behaviors that tend to cause falls.
Patient Navigation

A patient navigator is a person whose role is to remove the obstacles patients face in accessing and
receiving treatment. The concept was originally developed in relation to the treatment of cancer, which
can involve a maze of doctors' offices, hospitals, outpatient centers, and patient-support organizations, as
well as numerous problems with insurance and payment systems. The patient-centered medical home
model attempts to coordinate a patient's care through the office of the primary care provider; in this type
of office or in any other type of medical office, the medical assistant may function as a patient navigator to
help a patient with complex medical needs to access and receive appropriate referrals to community
services or additional health care services.

Memories from Practicum

Beth Ann Wilson: I couldn't believe how nervous I was before I went to my practicum the first day. I had
worked at several jobs and even done filing at a medical office during the summer when I was in high
school, but it felt totally different to know that I would be responsible to act like a "real" medical assistant.
Fortunately, the staff members at my placement were wonderful. They let me shadow one of the medical
assistants until I felt comfortable to work with patients on my own. They were also careful to expose me
gradually to each part of the medical office, so it didn't get overwhelming. The person who helped me the
most was Cheryl, the office manager. Every day she sought me out and asked how it was going. There was
one time when a physician asked me to take out a patient's sutures, and I hadn't even seen someone
perform that procedure. I didn't know what to say, but I told him I would find another medical assistant to
help him. Then I went to Cheryl. She found someone else to perform the procedure and made sure that I
had an opportunity to observe. I never could decide whether I liked checking patients in up front or
assisting the physicians better, as long as I had a chance to interact with patients. It has always made me
feel good to know that I am helping others. ■

Employment Opportunities

According to the U.S. Department of Labor Bureau of Labor Statistics, medical assisting is projected to
grow 29% between 2016 and 2026. An increase in the elderly population as baby-boomers age will
increase the demand for preventative services. Certification may help to distinguish a medical assistant
who meets recognized standards from an entry-level assistant.

The majority of medical assistants work in physicians' offices. Other common places of employment
include hospitals and offices of other health practitioners, such as chiropractors, podiatrists, and
optometrists. Medical assistants also work in outpatient care centers, schools or other educational
facilities, medical laboratories, government agencies, insurance companies, employment services, and
nursing care facilities.
The median annual income reported by medical assistants in 2018 was $33,610/year ($16.16/h), but
salaries vary depending on geographic location, skill level, and type of facility in which the medical
assistant is employed.

The most direct route for career advancement is probably to become an office, practice, or department
manager. This may require additional education, especially in business administration, but often
management skills can be learned mainly on the job. To become a medical assisting instructor, it is
necessary to have an Associate in Science degree or a higher degree in a related field and to be a CMA.
Clinical advancement usually requires additional training in a formal educational program preparing for
a health career, such as dental hygiene, laboratory technology, nursing, radiologic technology, or
respiratory therapy.

What Would You Do? What Would You Not Do? Responses

Case Study 1

What Did Beth Ann Do?

□ Looked in the back part of the office for an available staff member.

□ Asked the receptionist if she knew where one of the other medical assistants was.

□ Used the intercom to locate a medical assistant.

□ Checked the examination rooms with open doors to see if a medical assistant might be almost
finished checking in a patient.
□ Assisted the physician if she was unable to find another medical assistant to do it.

What Did Beth Ann Not Do?

□ Did not leave for lunch without finding someone to assist the physician.

□ Did not tell the physician that she was sorry she could not assist him at this time.

Case Study 2

What Did Beth Ann Do?

□ Agreed to draw the blood without complaining.

□ Tried to make the patient feel comfortable and confident.

□ Explained to Diane later that some patients do not want students to perform certain procedures.

□ Told Diane that she was glad Diane called her to help.
□ Reinforced that even if Diane's pride was slightly hurt, Diane did the correct thing by not showing this
to the patient.
What Did Beth Ann Not Do?

□ Did not make the patient feel as if she were asking for special treatment.

□ Did not tell Diane that she looked very young or unprofessional.

□ Did not talk about the incident as a funny story in the break room to other staff.
Case Study 3

What Did Beth Ann Do?

□ Told the patient that the physician asked her to recheck the blood pressure because it sometimes
changes when patients sit in a quiet examination room.
□ Found a private place to speak to Diane and agreed with her that sometimes it is really hard to hear
the blood pressure.
□ Explained to Diane that it is important to take and record the blood pressure correctly even if she has
to ask for assistance.
□ Reminded Diane that the staff understands she is a student and will not be able to perform every
procedure perfectly.
□ Offered to work with Diane to improve her technique.

What Did Beth Ann Not Do?

□ Did not talk down to Diane or try to make her feel bad.

□ Did not tell others in the office not to rely on Diane's blood pressure measurements.

□ Did not tell the patient that Diane had not been sure of her measurement. ■
Terminology Review

Key Term Word Parts Definition

Accreditation Credit or recognition from a regional or national organization for maintaining
certain standards.

Continuing education unit (CEU) A standard unit of measure of continuing education for
professionals defined as 1 contact hour by the AAMA but also commonly 10 contact hours of
participation.

Fee splitting The practice of sharing fees with colleagues, especially for making referrals.

Health coaching A process that helps patients to identify their values related to health, set
health goals, and take steps to meet their personal goals.

Initiative The ability to begin or carry through a plan of action independently.

Patient navigator A person whose role is to remove obstacles that patients face in
accessing and receiving treatment.

Practicum A supervised work experience that is required in an educational program

and usually unpaid. Formerly called an externship.

Risk management Processes to protect a health care facility from the risk of legal
action.

Time management Skills and techniques used to manage time to accomplish tasks and
meet goals.

Procedure 2.1

Locating and Defining a State's Legal Scope of Practice Outcome

Locate and define the legal scope of practice of own state Equipment/Supplies:

• Paper

• Pen

• Computer and printer

• Blank index cards

1. Procedural Step. Research the legal scope of practice for a medical assistant in your state.
2. Write a brief report summarizing what is included in the scope of practice for the medical assistant
and what is not. Include a discussion of the consequences for medical assistants and patients if the medical
assistant performs activities that are not included in the legal scope of practice. Describe
what procedures can and cannot be delegated to the medical assistant by a physician, by a nurse (nurse
practitioner or registered nurse) and by a physician assistant.
Principle. It is important to know how each state defines (or is vague about) the scope of practice for a
medical assistant if one is to practice professionally.
3. Procedural Step. Imagine two situations, one in which a medical assistant practices within the legal
scope of practice and one in which the medical assistant practices beyond the legal scope of practice.
Summarize each on an index card. On the back of the card explain how the situation relates to the scope of
practice for a medical assistant.
4. Procedural Step. Working in a small group, role-play the situations created by another classmate.
When everyone in the group has finished the role-play, engage in a group discussion to identify the
scenarios that do and do not fall within the legal scope of practice for a medical assistant.
Principle. Discussion helps a person to clarify and digest new information.

5. Procedural Step. Hand in your report and index cards to your instructor.