AAMC Reporter: January 2009

Viewpoint: PAs: Not a Silent Partner

Timi Agar Barwick, executive director, Physician Assistant Education Association

Steven Lane, associate executive director, Physician Assistant Education Association

With provider shortages projected in almost every health profession and significant changes likely to come to the health care arena in the near future, now is the time for unity and collaboration among health care providers, and for the development of a game plan for the future. In particular, while physician assistants (PAs) and physicians have worked closely together for 40 years, considerable potential exists to improve the coordination of educational and workforce planning activities between the two professions. Recent meetings among staff and leaders of the AAMC, the Physician Assistant Education Association (PAEA), and the American Academy of Physician Assistants (AAPA) have highlighted opportunities to strengthen the ties between these complementary and synergistic professions.

PAs have been members of the physician-led health care team since 1967, when the first PAs graduated from the Duke University PA program and entered practice. Today more than 70,000 PAs practice under the supervision of a physician, and that number is growing—with projected 5 percent annual growth, the number of PAs is expected to double by 2020. PAs continue to play an integral role in not only the physician-PA team, but the health care team as a whole, including nurse practitioners, clinical pharmacists, physical therapists, and others.

PAs are trained at 142 accredited PA programs across the United States. The majority (87 percent) are at four-year colleges, and more than 85 percent of programs now award a master's degree as the highest credential. Matriculants typically enter programs with more than three years of combined direct patient care and related health experience. Their formal education lasts an average of 26.8 months and includes basic medical sciences, behavioral and social sciences, clinical sciences and patient assessment, and some 45 weeks of supervised clinical instruction in the areas of family medicine, internal medicine, pediatrics, and other specialties. Students also cover health policy and professional practice topics, including regulatory, economic, and cultural issues, and the physician-PA team.

All physician assistants are trained as generalists, and historically their roots have been in primary care. Because PAs function through what is known as "negotiated performance autonomy," by which their scope of practice is determined through delegation by the supervising physician and the demonstrated skills of the PA, the profession is uniquely able to respond to the dynamic needs of the health care workforce. The percentage of PAs in primary care has declined in recent years, as PAs have increasingly entered the medical and surgical subspecialties, and in academic medical centers where utilization of residents has been limited by the 80-hour work week requirement. There is a critical need for data regarding PA practice patterns to effectively plan for health workforce needs, but data captured in large national health care surveys is woefully inadequate with respect to PAs.

Where PA programs and medical schools are co-located or overlap in their clinical training, the physician-PA team has benefited from shared training. In a 2004 survey conducted by the PAEA, 34 percent of PA program respondents indicated that the PA students completed at least one area of their didactic coursework with medical students. A quarter of responding programs indicated that at least one member of the program's core faculty provided formal didactic instruction for medical students (clinical medicine, geriatric medicine, patient evaluation, and physical diagnosis were among the most common subjects). A slightly lesser number (19 percent) of respondents reported that at least one core PA faculty member provided instruction to medical students during clinical clerkships.

For the past two admissions cycles, the percentage increase in the number of applicants through the Central Application Service for Physician Assistants (CASPA) has been more than double that of the American Medical College Application Service (AMCAS) (2006-2007 AMCAS data reported an 8.2 percent increase over the previous year's applicant numbers, versus 18.7 percent for PAs over the same period, with a slight increase in the number of programs.) Even without a national call for increased enrollment, PA program enrollment numbers are up significantly—16.7 percent between 2003 and 2007. Almost 90 percent of PAs surveyed said they would choose the PA profession again. The combination of salary, flexibility, and the condensed time in formal education (especially as it relates to debt) are certainly attractive to this generation. These facts suggest that health professions have much to learn about and from each other about growing their applicant pools to support increasing the number of providers.

Now, more than ever, it is important that the PA and physician communities collaborate. In the next several months the PA community and other stakeholders will consider what role, if any, the clinical doctorate degree might play in the future of the PA profession. Physicians will play an important role in that debate—and in ensuring that the physician-PA team remains flexible enough to meet future demands for health care services.

The physician-PA relationship is unique, but the success of this team approach can and should be replicated throughout the health care community. Forty years of practice have made explicit and implicit rules of supervision and delegation the cornerstone of PA practice, and this acquired knowledge can be shared as a best practice to help facilitate a better understanding of team functions.

PA education has long provided innovation, best practices, and leadership in medical education, and PAs have much to offer as health care professions come together to craft a game plan for success.

Editor's Note: The opinions expressed by the authors do not necessarily reflect the opinions of the AAMC or its members.