PAs in specialty care: The current trends

Richard Dehn, MPA, PA-C, DFAAPA

April 26, 2011

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Abstract  

Although the PA profession was created to bolster the primary care workforce, PAs have assumed increasing roles in subspecialties. This paper compares specialty prevalence between physicians and physician assistants, analyzes trends in PAs' specialty choices from 1997 to 2006, and suggests options for influencing these specialty choices in the future. The number of PAs is growing more rapidly in surgical and medical subspecialties than in primary care. Salaries loosely correlate with specialty choice, especially among specialties with the highest income. If there is a societal interest in encouraging PAs to practice in primary care, new economic or educational policies may be required. 

Will KK, Budavari AI, Wilkens JA, Mishark K, Hartsell  ZC. A hospitalist postgraduate training program for physician assistants. Journal of Hospital Medicine. 2010;57(2):94-98. 

Abstract  

Many hospitalist groups are hiring PAs to augment their physician services. Finding PAs with hospitalist experience is difficult. Employers often have to recruit PAs from other specialties or hire new graduates who have limited hospital experience. Furthermore, entry-level PA training focuses on primary care, with more clinical rotations centered in the outpatient setting. In light of these challenges, our institution created a 12-month postgraduate training program in hospital medicine for one PA per year. It is the first reported postgraduate PA hospitalist fellowship to offer a certificate of completion. The program's curriculum is based on the Society of Hospital Medicine (SHM) "Core Competencies" and is comprised of 12 one-month rotations in different aspects of hospital medicine supplemented by formal didactic instruction. In addition, the PA fellow completes "teaching modules" on various topics not directly covered in their rotations. Furthermore, this postgraduate physician assistant training program represents a model that can be utilized at almost any institution, academic or community-based. As the need for hospitalists increases, so will the need for trained physician assistants in hospital medicine. 

Ho P, Pesicka D, Schafer A, Maddern G. Physician  assistants: trialling a new surgical health professional in Australia. ANZ Journal of Surgery. 2010;80(6):430-437. 

Abstract 

Background: The Australia health workforce productivity Commission Research Report in 2005 identified workforce shortages. One of the recommendations is that new models of health care be established. As a result, South Australia is trialling United States—trained physician assistants in a pilot program. This paper summarizes the review of literature of the physician assistant role and safety in the surgical setting. 

Methods: A literature search using Medline and PubMed from 1966 until 2009 with key words: physician assistants, midlevel providers, surgery. The references of the results were also searched for suitable articles. The Google search engine was also used with the above keywords to search for latest developments from nontraditional sources. 

Results: There were over 200 suitable articles relating to the quality and safety of physician assistants. The overwhelming majority of the articles originate from the United States, and these vary in quality. There were 13 published studies identified that documented physician assistants in the surgical setting. 

Conclusion: From the published data, physician assistants have been shown to provide safe, high-quality care in surgical units. It is important that prior to their commencement, their role is defined to alleviate conflict and confusion in the team. Continued auditing should be conducted to monitor progress and impact. 

DISCUSSION 

From the beginning, one of the primary goals of the PA profession has been to train clinicians to help address a chronic shortage of primary care clinicians. Although aggregate data describing achieved success in meeting this goal in the profession's first decade is incomplete, anecdotal reports indicated that most PAs of that era practiced in primary care. Data published in 1993 compiled from multiple sources listed that 69.8% of the 939 US PAs in 1974 practiced in primary care, as did 67.3% of the 3,416 PAs in 1978, 55.8% of the 6,552 PAs in 1984, and 42.7% of the 13,500 PAs in 1992.¹ In contrast, 18.9% of US PAs practiced in general surgery or surgical subspecialties in 1974, dropping to 11.7% in 1978, rising to 17.6% in 1984, and to 29.7% in 1992. However, the trend away from primary care toward specialty practice over the past three decades has not been entirely linear, with some oscillations of new graduates taking their first job in primary care in greater numbers in the 1990s and again over the past 3 years.^2-4 Clearly, the US PA profession has evolved toward a diverse set of specialties, with a large but continually decreasing minority of PAs practicing in primary care and an increasing proportion of PAs practicing in specialties. Also of note is the fact that PAs were practicing in surgery at the profession's onset, although in relatively small numbers. 

The article by Morgan and Hooker documents the movement of PAs from primary care to surgical and medical subspecialties from 1997-2006. During this time, the PA workforce in the United States essentially doubled (a 100% increase); however, the family practice/general practice PA workforce increased only 39%, and other primary care areas such as general internal medicine, general pediatrics, and obstetrics/gynecology increased only 61%, 87%, and 72%, respectively. In contrast, during this same period, the internal medicine subspecialty PA workforce increased 262%, and the surgical subspecialty PA workforce increased 186%. Thus, while a substantial increase in the number of PAs graduating during this time led to an increase in the number of PAs in both primary care and specialties, the vast majority of those graduating ultimately ended up in a specialty rather than primary care setting. This article also explores possible factors that may explain the attraction of specialty practice, such as physician-to-PA ratio, the salary of new PA graduates in each specialty, and the mean salary of PAs working in each specialty. Data from this article show that new graduates choosing the highest-paid specialty out of school, emergency medicine, make 17% more than those who chose to work in family medicine ($78,305 versus $66,899), compared to the average PA salary in the highest-paid specialty, cardiovascular/thoracic surgery, which is 33% higher than the average PA salary in family medicine ($104,681 versus $78,893). The authors hypothesize that the greater market demand for PAs in specialties may be less dependent on the relatively modest difference in PA salaries and instead more dependent upon the salaries of the physicians in the specialties, which consequently makes the relative value of a PA's contribution more financially valuable in settings containing higher physician salaries. In this scenario, demand for PAs will be highest where the PA will save time of physicians whose salary is highest, thus modeling the highest current demand for PAs in specialties where physician salaries are highest. 

The article by Will and colleagues describes the establishment of a new hospitalist PA postgraduate training program. The article describes a relatively new nonprimary care area where PAs have demonstrated value, with workforce demand for experienced PAs in this specialty justifying the establishment of postgraduate training and illustrating another example of increasing opportunity for PAs in specialty practice. This article discusses factors contributing to increased demand for PAs as hospitalists, including the 2002 Accreditation Council for Graduate Medical Education (ACCGME) restriction on residents' work hours as well as studies that document the role of nonphysician providers in improving patient outcomes.  

The article by Ho and colleagues reviews the utilization of PAs in surgical settings, both in Australia as well as in other countries. The PA profession is currently in its early development in Australia, with the goal of producing additional primary care providers to address health workforce shortages. The article states that in response to anticipated challenges to the Australian health care system, multiple new health care models are being explored, including the use of PAs. US-trained PAs are currently involved in a trial surgical project in South Australia. The establishment of a PA profession in Australia appears to parallel the establishment of the profession in the United States, whereby it was intended that most PAs would practice in primary care settings. However, some PAs may provide value in other specialties even at the profession's establishment. As shown earlier in this section, a small proportion of US PAs practiced in surgery very early in the profession's history, and this experience may be also playing out in Australia as the profession is created.  

Very little is known about why PAs choose their eventual practice specialty or why they may change specialties during their career. More research is needed to help identify factors associated with PA practice choices. JAAPA

Rick Dehn is a professor in the School of Health and Human Services and chair of the Department of Physician Assistant Studies at Northern Arizona University, Flagstaff. He is a member of the JAAPA editorial advisory board. The author has indicated no relationships to disclose relating to the content of this article.

REFERENCES 

1. Cawley JF. Physician assistants in the health care workforce. In: Clawson DK, Osterweis M, eds. The Roles of Physician Assistants and Nurse Practitioners in Primary Care. Washington, DC: Association of Academic Health Centers; 1993. 

2. Oliver D, Baker J, Donahue W. First Annual Report on Physician Assistant Educational Programs in the United States, 1984-85. Association of Physician Assistant Programs. May 1985. 

3. Simon A, Link M, Miko A. Twelfth Annual Report on Physician Assistant Educational Programs in the United States, 1995-96. Association of Physician Assistant Programs. May 1996. 

4. Twelfth Annual Report on Physician Assistant Educational Programs in the United States, 2008-2009. Physician Assistant Education Association. Jan 2010.  

From the April 2011 Issue of JAAPA