If you hold a cat by the tail you will learn things you cannot learn any other way. Mark Twain [1835-1910]

Postgraduate education is an avenue of additional formal training that a few PAs opt for. It is not a cornerstone of PA education but an idiosyncrasy of the American PA movement. But to what degree does this extra education benefit the individual, society, or the training institution?

The early developers of the PA movement had general medicine in mind. While the intent was for this new provider to be broad-based and primary in nature, this did not preclude PAs from assisting in surgery or acquiring specialized roles. In fact, the first PA students learned how to repair ECG machines and oversee pressure chambers. Yet 4 years after the graduation of the first formally trained PA, a postgraduate program in surgery was inaugurated at Montefiore Hospital.1 The program was developed to staff house officers with PAs. That program and 44 others, spread over 16 medical and surgical specialties, are operational in 2009.2

Little attention has been paid to this aspect of PA development. However, in spite of the lack of data, opinions for or against have arisen regarding this activity.3

The argument for postgraduate education The PA of the new century needs to be more specialized. Technology, expectations, and trends dictate this, and medical educators have called for a shift in PA education.4 A rationale for this opinion is that PA education is too short to learn the intricacies of modern medicine. Concentrated experience in a specialized setting is apprentice development at its best, with scholarly activity and tertiary medicine intertwined.5,6

Rheumatology is a paradigm of this trend. A graduate PA can enter a 12-month rheumatology fellowship, providing care in more than 400 patient encounters and offsetting demands for access by screening patients regarding more intensive care. The stipend for this fellowship is $36,000. The PA learns immunology, acute and chronic disease management, a broad spectrum of general medicine (from pediatrics to geriatrics), and procedural skills. At completion, the PA can immediately manage patients in any rheumatology setting with minimal supervision. In 1 year, a PA can offset much of what takes a doctor 4 to 6 years of postgraduate training to acquire.

Such additional training can also serve as a bridge for the newly minted PA who is unsure of her or his skills upon graduation. A structured mentorship enables the PA to reach high potential while drawing on ideal role models along the way.

The argument against postgraduate education Four decades of experience in deploying PAs trained in primary care says a lot. PAs appear to be quick to learn and adaptable to a broad spectrum of medical services. The evidence for PA residencies' producing something more than a cadre of house officers is limited.2 At best the residencies generate approximately 120 graduates annually, 2% of the US physician assistant graduation rate. Takers are few, the growth is stagnant, and more than a third of the programs have folded.

Emerging evidence indicates that the value of PAs may be their flexibility and broad-based skill set, which permits adaptation to a shifting health care environment. The PA in family medicine may be an ideal hire for orthopedics, not to be in the operating theater but to provide fracture management, discharge planning, and outpatient procedures. This adaptability may be a defining attribute of PAs that differs markedly from the doctor or nurse practitioner fixed in a specialty. In fact, career elasticity may contribute to PA job satisfaction.7

Protracted training for 12 to 24 months results in the added burden of opportunity costs and delays in career entry and repayment of debts. Deferring a PA from working in a semiautonomous setting for that period of time means fewer patients are seen, those seen are done so inefficiently, and the lifetime employment span is shortened by the training years.

Most arguments tend to be based on the logical consequence of the premise. I suggest the premises for and against PA residencies are inadequately laid out. More than 3 decades of experience have generated little more than strongly held opinions because postgraduate PA programs have not produced evidence of their value. If PA education is to be the laboratory of experiment and change for a new era of health care infrastructure, it must be the leader in proving its mettle. Thus far, it appears to be the quiet face of indifference. JAAPA

REFERENCES

1. Rosen RG. The Montefiore Medical Center experience. In: Zarbock SF, Harbert K, eds. Physician Assistants: Present and Future Models of Utilization. Vol 1. New York, NY: Praeger; 1986:83-89.

2. The Association of Postgraduate PA Programs. Association of Postgraduate Physician Assistant Programs Web site. http://www.appap.org/. Accessed April 9, 2009.

3. Knott P. Postgraduate education for the physician assistant: Where are we heading? J Physician Assist Educ. 2008;19(3):6-7.

4. Whitcomb ME. The shortage of physicians: a challenge for the physician assistant profession. J Physician Assist Educ. 2007;18(1):5-6.

5. Salyer SW. A clinical doctorate in emergency medicine for physician assistants: Postgraduate education. J Physician Assist Educ. 2008;19(3):53-56.

6. Reynolds EW, Bricker JT. Nonphysician clinicians in the neonatal intensive care unit: Meeting the needs of our smallest patients. Pediatrics. 2007;119(2):361-369.

7. Marvelle K, Kraditor K. Do PAs in clinical practice find their work satisfying? JAAPA. 1999;12(11): 43-50.