Table 2.

Barriers to Medical Assistant Role Shifts

BarriersSample Quotations
Insufficient MA understanding of the PCMH conceptI (researcher) asked if there is ever conversation between her (MA) and the doctors about the [PCMH program]. She said no…she wishes they talked about it more in this practice. She feels that the MAs understand their new tasks, but she doesn't feel that they understand the “PCMH or any of the pilots.” Her understanding of the concept of the PCMH is “to have the patient feel comfortable and confident that we will take care of all their medical needs.” (fieldnote, Practice 10)
[The MA] knew about the metrics and was able to name BMI and smoking as examples. She said, “It's not really a change but now we do things 100% of the time”… like taking someone's BMI every time they come in which is, “kinda dumb…especially for acute visits.” (fieldnote, Practice 9)
Lack of time for added responsibilities[The MA] gets concerned sometimes when more tasks are added “because more responsibility means that it takes longer.” She said that when 4 clinicians are working and there's only one MA rooming, it can get very stressful. (fieldnote, Practice 15)
Additional workload without additional pay[The PCC] has heard that there has been some turnover and there is good amount of frustration within the ranks of the MAs. Apparently they haven't had raises in 3 years and the demands of the job are increasing—they are citing this kind of work as an example of something that is adding to their workload. (fieldnote, Practice 9)
Lack of MA knowledge or trainingOne thing [PCC] is frustrated by is that she feels for the most part, the MAs are just “memorizing tasks and not really thinking.” She (PCC) has been surprised by the low level of clinical knowledge that the MAs have. For instance, she said that one MA asked her if a high PT/INR meant that it is thick or thin. [The PCC] said that when she was talking to MAs about the metrics, one of them said, “Good luck getting patients to get a colonoscopy,” and someone else said (regarding colonoscopy), “What? Does [insurance company] want patients to live forever?” (fieldnote, Practice 10)
[If I could change one thing] I think that it's getting the medical assistants to think more like doctors, and to kind of function without being told, doing things without being told… we have mostly medical assistants, they don't really think like nurses. They're not that trained…nurses think differently, but they cost a lot more money…. I think the medical assistants try, but they just don't have that knowledge base enough to kind of anticipate…So that's the price we pay for hiring lower trained people. And I guess that you can train them. They're reasonably smart; they're not dumb. But, it takes a lot of work. (physician interview, Practice 9)
Reluctance to delegate tasks to MA[A nurse practitioner commented that] the MA shouldn't be allowed to do the patient's health maintenance (ie, fill the standing orders that the health maintenance screen says the patient needs). “They just see it as a checklist and they treat it that way. It's not a checklist!” She explains that if a patient has not gotten a test or followed up on something they've been told to follow up on, then just re-ordering probably isn't going to help. She said that health maintenance “should be a conversation.” (fieldnote, Practice 4)
Uncertainty on how to make workflow changes more routine[Handing out smoking cessation handouts] was not part of the routine initially; it was new and it wasn't getting done all the time… [The health plan] was good at telling us what they wanted us to do, but not really how to do it. You know, they wanted these metrics, they wanted these reports, they wanted…but there wasn't a lot of help. We were trying to figure it out ourselves. (physician interview, Practice 1)
Staff turnoverOne office manager described this as bittersweet. An MA of eight years who had trained in the practice since her internship had gradually been entrusted with increased responsibilities, developed skills, and become a practice leader. Based on the competencies the practice had nurtured in her, she was able to secure a new position at the local hospital that included higher compensation and tuition support for her nursing program. (fieldnote, Practice 6)
Change fatigueThe MAs worked so hard last summer—they busted their [butts] pulling charts. Now, that's all over, but then it was this iPad Depression screening project that had a 27-page manual for them to read, and then [this PCMH project] came in—so it's just been a lot. (Clinical supervisor, Practice 9)
  • BMI, body mass index; MA, medical assistant; PCMH, patient-centered medical home; PCC, population care coordinator; PT/INR, prothrombin time/international normalized ratio.