Why do PAs choose the practice specialties they do? While research has provided some insight into the factors that influence the specialty choices physicians make, there is very little research into PAs on this topic.

PAs and physicians have been trending in the same direction in recent years, toward greater specialization and away from primary care practice; however, physicians and PAs have many unique differences that may complicate a prediction that PAs will eventually mirror physician trends. Physicians have been on a long-term trend toward increasing specialization since before World War II, and that trend has generally been constant. In contrast, PA specialization has oscillated back and forth between primary care and specialty care several times over the 40 years of the profession's existence.

PAs began in the 1970s as almost an entirely primary care profession. In 1974 about 70% of PAs practiced in primary care; but over the ensuing 18 years, enough PAs had entered specialty practice that by 1992 only 43% practiced in primary care. New graduate data mirrored this trend: in 1986 60% of new graduates chose their first job in primary care, a number that dropped to 48% in 1989. Between 1988 and 1996 this trend reversed, and the number of new graduates taking their first job in primary care increased to 62%, only to decrease steadily to 34% in 2003. Since then this trend has again reversed, rising to 50% in 2008. Thus, unlike physicians, PAs have not exhibited a consistent trend toward specialization but instead have shown wide variation, possibly in response to changing market demands.

Survey data from medical students indicate that they make specialty choices often based on lifestyle and salary. With high medical student debt at graduation, it is no surprise salary would be a big factor in physician specialty choice. Additionally, some specialties are perceived as providing a more attractive lifestyle. Primary care does not rank high in either of these characteristics—thus, the thinking goes, physicians are less likely to select primary care specialties. Additionally, physician culture has valued specialty care for many generations, as most training occurs in tertiary care academic medical centers that highly value specialized medical knowledge. Despite the valiant efforts of some physician educators to counter this cultural bias, the devaluation of primary care practice is a common attitude in physician training.

In contrast, PA training, with its “generic” core knowledge orientation, is designed to train competent primary care providers. Additionally, PA accreditation standards mandate clinical training in family medicine, pediatrics, internal medicine, women's health, mental health, surgery, and emergency medicine; thus over half of the mandated clinical curriculum is in primary care. I am not aware of PA programs that devalue the culture of primary care, so graduates likely do not internalize an anti-primary care bias in their training. While PA students are certainly graduating with increasing debt, that debt will be less than graduating physicians. While physician specialty choice can make a big difference in salary (specialty to primary care salary comparison ratios can be over 500%), in the PA profession specialty to primary care salary ratios are much lower (approximately 133%). Thus in the PA profession salary may be a much lower motivation for specialty choice.

Another important difference is that in physician training, specialty choice is usually career-long, as the cost of changing specialties is high. In the PA profession, changing specialties during one's career is common. A majority of PAs change specialties, and many change specialties several times during their career. This makes the profession very “fluid” and likely contributes to the PA profession reversing specialty choice trends quickly.

This topic certainly deserves to be researched, as health care in the United States will face many workforce challenges in the future that will require some degree of matching training processes with demand. While we may speculate as to why PAs choose the specialty they do, we really don't know much about the factors impacting this important choice at graduation or when a PA chooses a change of specialty.

Rick Dehn is a professor in the School of Health and Human Services and chair of the PA program at Northern Arizona University, Flagstaff. This blog post expresses his personal views and does not express or represent the views or policies of AAPA.