Physician assistant (PA) Erin Kelly-Makol, PA-C, remembers the flood of emotions she and her colleagues felt last spring as they began caring for a rapidly growing number of patients with COVID-19.
As members of the Brigham’s Physician Assistant Clinical Educator (PACE) Service — a general medical service staffed by attending hospitalists and PAs — Kelly-Makol and her colleagues were among the first medical teams that were reassigned to care for hospitalized patients with COVID-19 in March 2020. Nearly one year later, PACE clinicians remain on the pandemic’s front lines — along with nurses, residents, respiratory therapists and other interprofessional team members — continuing to care for COVID-19 patients without interruption.
Amid concerns about caring for very sick patients, navigating rapidly changing clinical protocols and fearing they would catch the virus themselves, Kelly-Makol recalled another strong feeling from those early days of the pandemic: unity.
“As tight-knit as we were on the General Medicine units, the COVID teams have made us even closer,” said Kelly-Makol, who has been part of the PACE Service for eight years. “When we were starting to provide care on the Special Pathogens Unit, there was a lot of anxiety. We started this group text that became a stream-of-consciousness thread for our thoughts, concerns and occasionally humor. It kept us all smiling and feeling like we weren’t alone.”
Established in 2005, the PACE Service is one of four branches of the Brigham’s Hospitalist Service, which delivers inpatient care for the wide range of conditions that general medicine covers. This can include patients with anything from asthma exacerbations to heart failure, HIV, gastrointestinal bleeds, new cancer diagnoses, acute rheumatology disorders and more. While PACE’s role has evolved considerably due to the pandemic, its clinicians say their culture — defined by multidisciplinary collaboration, mutual respect and heartfelt connections — has remained the same since day one.
“The core value of PACE is that we are in this together. There’s an understanding that nobody can do this work by themselves,” said Matthew Vitale, MD, medical director of the PACE Service. “My favorite part of this job is watching the ways team members help each other grow and support one another in circumstances that can be very trying. These incredible clinicians care for each other, acknowledge their struggles and come together to do a phenomenal job every day.”
Marissa Cauley, PA-C, one of the service’s two chief PAs, said PACE strives to create an environment where all perspectives are heard.
“What makes PACE special is the interdisciplinary collegiality between physician assistants and attending physicians. We really work together as a team,” Cauley said. “When you feel respected and that your opinion matters, it makes coming to work that much more enjoyable. You’re valued, and that means a lot.”
Until PACE was formed, the Brigham’s Hospitalist Service was made up of teaching services consisting of attendings, residents and interns. In 2003, a nationwide regulatory change went into effect that limited resident work hours. While the new restrictions represented an important milestone in workplace safety and well-being for trainees, they also created staffing challenges at hospitals around the country, including the Brigham.
The Brigham sought to bridge this gap by tapping a historically overlooked pipeline of advanced practice providers — physician assistants. The PACE Service was born.
During a typical shift, each PACE team is staffed by two PAs and an attending hospitalist who round together, develop clinical plans and care for patients in collaboration with nurses, social workers, Care Coordination staff, physical therapists and other multidisciplinary colleagues. Overnight, the teams are covered by a member of the Hospital Medicine Nocturnist Service.
One point of pride for PAs is that PACE is not a triaged service, meaning that patients aren’t assigned to a PA team or resident team based on the complexity of their illness. Both teams are considered equally capable of delivering advanced, expert care in partnership with attending physicians on the General Medicine and Special Pathogens units.
“There is no patient too complex for our PA team,” said Leanne Wines, PA-C, co-chief PA of the PACE Service. “We’re really proud to be an essential part of the General Medicine Service.”
When PACE first launched, it consisted of one team of five PAs and three attendings, with a typical daily census of about 15 patients. Today, PACE now comprises three teams — known as PACE A, B and C — supported by a total of 17 PAs and up to 40 attendings, caring for up to 44 patients per day.
“We were one of the first academic medical centers in the country to adopt this model,” said Christopher Roy, MD, medical director of the Hospitalist Service, who led the PACE Service’s launch. “I’m so proud of how the service has grown.”
The service’s team-based approach to care is at the heart of its clinical operations, Vitale said.
“Attendings and PAs jointly make decisions about how to proceed in an area of ambiguity, such as a medically complicated patient at end of life whose family is making a choice between ICU or comfort measures,” Vitale said. “We put our heads together to come up with the best answer we can, based on the patient’s and family’s goals of care.”
Wines noted that the breadth of expertise and diverse backgrounds in PACE can be especially useful in caring for general medicine patients, whose medical needs are often varied and complex.
“The range of experience on the team is really impressive,” Wines said. “Marissa and I came from cardiac surgery, so we bring those cardiology skills. We also have PAs who came from neurosurgery, urogynecology, primary care and more. There are people on the team with 15 years of experience and some who just graduated last spring. All of this means we’re constantly learning from each other and tapping into different skill sets.”
Responding to the Surge — and Beyond
Since the arrival of COVID-19, the PACE Service has played a vital role in pandemic response. But when the spring 2020 surge set in, the teams quickly realized they needed more help. To manage the sharp increase in patient volume and complexity during the initial surge, about 40 PAs from other areas of the hospital were temporarily reassigned to the PA Special Pathogen Teams.
To help their colleagues acclimate to this new assignment, PACE PAs quickly created information packets, training manuals and in-person training shifts so that reassigned PAs would have the resources they needed to succeed.
“We were not only caring for COVID patients, but we were also training PAs from Surgery and OB/GYN on how to care for General Medicine patients,” Wines said. “It was a lot on our team during an already stressful time, but we were so grateful for the help because we absolutely needed it.”
Kelly-Makol said the extraordinary compassion, teamwork and dedication she’s witnessed over the past year has reminded her of what being part of PACE is all about.
“Once you’re in, you feel like family,” she said. “It’s a special group of people, and there’s never been a time when I felt unsupported. You truly know that, no matter what you’re facing in the day, you’ll have the support of your peers. We’re there for each other no matter what.”
“Behind the Scenes at the Brigham” is an occasional series in Brigham Bulletin that provides a glimpse of the people whose everyday contributions help make the Brigham a world-class institution. Is there a team you’d like to see featured? Send your ideas to firstname.lastname@example.org.