Physician Assistants in American Medicine: The Half-Century Mark
Published Online: October 22, 2013
James F. Cawley, MPH, PA-C; and Roderick S. Hooker, PhD, PA
A prevailing issue within the US medical workforce is the adequacy of the physician supply to meet the needs of a nation undergoing health service expansion. Despite an increase in the number of medical schools and boosted enrollment, substantial shortages of physicians are predicted. The Association of American Medical Colleges estimates a shortage of 124,000 full-time equivalent (FTE) physicians by 2025, with primary care accounting for the largest share of the deficit (37% or ~46,000 FTEs). Family medicine put this primary care estimated shortage at 52,000 physicians by 2025. Beyond calling attention to a physician shortage in general, and a diminishing supply of primary care physicians in particular, there is a clear indication that other providers are needed.1 Increasingly, physician assistants (PAs) are expected to help fill workforce shortages. As the profession approaches the half-century mark, an update of the PA profession may serve as a reference point for policy analysis.
The PA was a workforce idea created by physicians in the 1960s as a policy response to the shortage and uneven distribution of generalist doctors. The intention was to increase the public’s access to healthcare.2 The National Commission on the Certification of Physician Assistants records that there are approximately 100,000 PAs who have ever been certified.3 Taking into account those who have left the workforce and those who are entering as new graduates we estimate 89,500 PAs with active licenses in 2013. There are 173 PA programs, with 60 in development. While all are trained in the generalist model, PAs are employed in primary care, specialty, and subspecialty medicine, and work in collaboration with physicians in most clinical practice settings.4
DEFINITION AND LEGAL STATUS
Physician assistants are health professionals licensed to practice medicine with physician supervision. They share an interdependent relationship with physicians sociologically described as “negotiated performance autonomy.”5 The PA scope of practice corresponds to the supervising physician’s practice and varies according to the training, experience, facility policy, and state law. Qualifications for PA licensure are (1) graduation from an accredited PA program and (2) passage of the Physician Assistant National Certification Examination administered by the independent National Commission on Certification of Physician Assistants. Licensed PAs have prescribing authority in all states, although laws vary with regard to certain prescribing privileges and supervisory requirements.6
In their work, PAs routinely perform a comprehensive range of medical duties, spanning primary care to high-technology specialty procedures. In primary care, they serve as front-line providers working typically with family physicians. In surgery they serve as first assistants as well as providing preoperative and postoperative care.7 In some rural areas where physicians are in short supply, PAs work semiautonomously, conferring with their supervising physicians as needed and as required by law.8,9
As of 2013 there were more than 173 accredited PA programs, a number that has grown rapidly over the past decade (Figure 1). An additional 45 programs have applied for initial accreditation; 20 more are in the development pipeline progressing toward accreditation status by 2017 (J. McCarty, CEO of the Accreditation Review Commission on Education for the Physician Assistant [ARC-PA], written communication, April 2013; ARC-PA website updated April 12, 2013). The average program length is 27 months, operates year-round, and typically comprises 1 year of classroom and laboratory instruction and a second year of clinical experience.10 Physician assistant programs graduate, on average, 44 persons per program each year. The 2012 graduating cohort was 7300 (estimated); this number is projected to increase to 9000 annual graduates by 2020.11 Two-thirds of matriculates are female and the median age at graduation is 29 years (range, 23-55 years).
Although accredited PA programs have demonstrated compliance with a core set of educational standards (ARCPA Standards, 4th edition), they have the discretion to offer a variety of academic degrees, with the master’s degree as the norm. The curriculum resembles a competency-based (and shorter) form of medical education with basic sciences and clinical rotations. Students complete an average of 2000 hours of supervised clinical practice prior to graduation with the average length of clinical clerkships approximately 52 weeks.10
From a policy standpoint, PA education has been supported through Title VII, section 747, which provides incentives for programs to have diverse student selection, a primary care training focus, and deployment to rural and underserved settings.12 Since the early part of this century Title VII funding has been reduced for PA education with an exception in 2010 when one-time funding was created under the American Recovery and Reinvestment Act of 2009. During this phase, Expansion of Physician Assistant Training grants were used to bolster primary care. As of 2012, 39 of the 173 PA programs received some amount of federal training support.
Typical PA programs are sponsored by a university school of medicine, school of health sciences, or similar college within the institution.13 An average start-up cost of a PA program is approximately $2.5 million (direct cost in 2010 dollars) spread over the first 5 years.14 Without federal start-up funds, the cost is borne by the home institution. Tuition cost of a PA education averages $65,000 (2010 dollars; 28 months).10 Student debt is estimated around $55,00 on average with a range between $0 and $150,000 for 2012.15
In 2013, more than 89,500 PAs held an active state license to practice. Approximately 80% of all PAs are under the age of 55 years, making this one of the more youthful health professions (Figure 2).3,16 The median age of PAs in clinical practice is 41 years (range, 23-74 years); 65% are women.4,10
Although PAs are widely distributed across the nation, the highest density per capita is in Alaska and the lowest in Mississippi. New York, Pennsylvania, Florida, California, and Texas have the greatest number of PAs and also have the largest concentration of PA programs per capita. Physician assistants working in nonmetropolitan census tracts are found in every region, but more so west of the Mississippi River.17
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