Kim Brunisholz, MST

 To determine predictors of physician assistants (PAs) to retire or to permanently leave clinical practice. The intent was to create a measure of retention and attrition for purposes of forecasting PA supply.

 All PAs 55 years or older who were nationally certified in 2011 were surveyed.

Statistical analysis included descriptivemeasures utilizing means, standard deviations, range, and proportions for all survey questions. Univariable analysis using 

 test for the categorical variables determined gender differences in participants’ intent to retire. A studentized t test analysis for continuous variables was used to compare differences across genders. The estimated time interval until retirement was calculated using reported values from participants and then subtracting their projected retirement age from current age. The same calculation was used for estimating PA career length from date of graduation to retirement. For all analyses, a 

.05 was considered statistically significant.

 A total of 12,005 were eligible and surveyed online; 4767 responded (38%). The mean age was 60 years and the years in clinical practice was 25. When asked to predict a retirement date or age, the mean duration of working beyond age 55 years was 12 years (range 5 to 21). Most respondents reported being confident they were on track to retire with an adequate income. The significant differences that emerged were that men were more confident than women in preparing to retire, having enough money for medical expenses, and being able to live comfortably in retirement. Men more than women stated that, if forced to retire, they were more confident in the preparation to do so.

 PAs 55 years and older report they are likely to delay retirement from practice until age 67 years, on average. Women were less confident than men in retirement preparation. This age prediction expands career projections and refines forecasting models for the profession. Correlations based on expectation-action chain of events should be developed by periodically measuring how often intent and reality coalesce.

		American physicians developed physician assistants (PAs) 50 years ago and all are trained in the medical model.

		Utilization of PAs is a key component of primary care access.

		The organization and administration of PAs is poorly understood.

		Predictive modeling of a health profession requires understanding all the components of a career, from graduation to attrition.

For many workers, retirement represents a milestone. The traditional view is that, after a lengthy phase of labor, individuals are rewarded with a new segment of life free from the responsibilities of their vocation. As society has changed, the concept of  retirement has also changed, evolving to mean more than freedom from work. The elements of retirement that have generally been considered most important—financial security and leisure&mdash;retain their significance but are now accompanied by issues that reflect social shifts, such as self-fulfillment, a sense of self-worth, social interactions, and intellectual stimulation. As life expectancies have increased, and the period of retirement has lengthened, many retirees are presented with unexpected challenges. For some, the loss of valuable social, intellectual, and structural constants may be delaying retirement.

 For others, retirement may be coming at a time of dwindling energy and interest in one’s work. Such variables comprise some of the many factors that influence retirement decisions. These factors are also important because the oldest of the baby boomers have begun entering retirement and their patterns of retirement are not the same as their parents’.

 In addition to this new generation of older physician assistants (PAs), the lack of reliable information on retirement patterns within a profession makes it difficult to predict the size and level of activity.

While the American PA profession can be viewed as a viable labor force with young entrants and 5 decades of growth and maturity, it is also a time when a significant number are retiring. Since the first large cohort of PAs trained during the 1970s, the coming decade will provide an opportunity to observe how this segment of the health workforce makes retirement choices. Limited evidence suggests that many workers, instead of dropping out of the medical workforce completely at age 65 years, may choose to remain in practice to some extent, though not necessarily maintaining the same activity level or doing the same kind of work.

 If retirement is understood to mean complete cessation of medical practice, it should be seen as the end point of a continuum of changes in medical practice as a PA ages. But prior to full retirement, many other changes in medical practice may have occurred, such as  reduction in workload and narrowing of the scope of practice. These changes present significant implications for medical care  provision and PA workforce planning. Thus, the potential impact of the aging of the PA workforce should be examined from the  broader perspective of changing medical practice patterns, rather than from the narrow focus of retirement. Information suggests that some older PAs still want to remain clinically active even past traditional retirement age.

 At what level of activity and at what  capacity is unknown. In respect to the PA profession almost nothing else is known about this subject.

The literature regarding retirement of physicians and nurse practitioners (NPs) is as limited as that of PAs. A survey of specialist physicians’ intention to leave clinical practice in urban California was undertaken in 2002.

 The sensitivity of the AMA Masterfile practice status as a measure of actual departure from clinical practice was 9.0 percent, and the positive predictive value was 53 percent. Allowing for a 2-year reporting lag did not substantially change this observation. Self-reported intention to leave clinical practice had a sensitivity of 73 percent and a positive predictive value of 35 percent as a measure of actual departure from practice. The strongest predictor of both the intent to leave clinical practice and actual departure from practice was age (the older the subject the more likely retirement would occur when they said they would retire). Physician dissatisfaction had a strong association (odds ratio [OR] = 5.6) with intention to leave clinical practice, but was not associated with actual departure from practice.

At the time of this survey (2011) the profession nears a half-century mark. An estimated 100,000 PAs have ever graduated from an accredited program since 19676 and death has removed at least 900 from that roll (personal communication, E. Bush, AAPA Membership Division, August 2012). Yet in spite of a significant cadre of PAs retired and intending to retire within a decade the profession remains a youthful one; the average age at graduation is 29 years, mean age is 44 years, and 86% of clinically active PAs are under the age of 55 years. We undertook a study on the retirement intent of PAs.

This research builds on other work in the retirement of health professionals. One study identified a cadre of PAs working into their seventh decade and a second study on PAs already retired.

 We suggest there is compelling reason to know the duration of a health career as workforce models of supply and demand are constructed and intent to retire will assist modeling efforts. This work comes at a time in the United States when more skilled medical labor is needed for addressing a rising demand for more medical services. The time span from graduation to permanently leaving the clinical workplace will determine staffing models and influence educational pipelines. A trend toward early (or delayed) retirement has important implications for the individual as well as society. However, most models of retirement decision making offer little in terms of predicting or understanding the timing of retirement.

It is this area of retirement decision making that we set out to explore. Our research centers on 1 question: What is the retirement intent of physician assistants?

Because we wanted to identify clinically active PAs we turned to a national registry: The National Commission on Certification of Physician Assistants (NCCPA). All graduates of an accredited PA program are required to pass a national certifying examination to be eligible for a state license to practice as a PA. To maintain certification PAs had to register that they had accumulated 100 continuous medical education hours every 2 years and take a recertifying examination every 6 years.

 The NCCPA registry has been a repository of all certified PAs since 1974 and its accumulative holding is near 100,000 at the time of this study.

An online survey instrument was sent to all NCCPA registrants 55 years or older who were currently certified due to biennial maintenance and considered clinically active (or eligible) to hold a license as a PA. The survey originated within the office of the NCCPA using NCCPA letterhead and targeted an individual by name. While the research team developed the survey, the administration of the survey was by the NCCPA staff. All names of respondents were deleted prior to transferring the results to the research team and no attempt was made to identify any individual. Because surveying older PAs was theorized to have a lower than usual response rate, 2 electronic mailings were sent a month apart.

The survey instrument was submitted online, and consisted of 30 questions. The NCCPA staff reviewed the data obtained from the online survey and presented the results to the research team after it had been depersonalized and aggregated to avoid any discriminating identification.

The survey instrument was based on retirement decisions of older Americans and adapted from one used by the Bureau of Labor Statistics.2 Questions covered personal demographics (eg, age, gender, marital status), practice characteristics, and career plans (eg, plans for retirement, reasons for choices). If the individual was retired, a separate set of questions inquired about when in their career they retired and why.

Statistical analysis included descriptive measures utilizing means, standard deviations, range, and proportions for all survey questions. Univariable analysis was performed using 

 test for the categorical variables to determine gender differences in participants’ intent to retire. A studentized t test analysis was performed for continuous variables to compare differences across genders. Description of the estimated time until retirement was calculated using reported values from participants. Time to retirement was calculated by subtracting estimated retirement age from survey age as reported by study respondents. For all analyses, a 

.05 was considered statistically significant. All analyses were performed using SPSS (version 17.0;SPSS, Chicago, Illinois). The University of Utah Institutional Review Board approved the study on July 27, 2011 (IRB_00051290).

The survey was administered mid-year 2011. A total of 12,005 PAs out of 73,000 in the NCCPA database met the screening criteria for 55 years or older, were currently certified as of May 2011, and were considered clinically active (or eligible) to hold a license as a PA. A total of 4767 responded (38%); 625 reported they were retired, removed from the intent to retire analysis, and reported elsewhere since their intention had already been realized.7

Of the 4142 clinically active, non-retired PAs, 45% were female (

). The mean age was 60 years (median 59 years, range 55 to 80 years).

The mean age at graduation for this older cohort was 34 years and the mean age of intended retirement was 67 years with no significant difference between genders (

). The majority of respondents (55%) had spouses with retirement plans.

We asked PAs about preparedness for retirement with a series of questions. These questions centered on confidence in being prepared to retire, able to retire within the next 12 months, to live comfortably, and to take care of medical expenses (

). The percent of “very confident/somewhat confident” responses in a forced-choice method ranged from 38 to 70% depending on the question. More than two-thirds reported they were preparing to retire on schedule. Significant differences that emerged between men and women were in their confidence in preparing to retire (

 <.001), confidence in having enough money for medical expenses (

 <.001), and if forced to retire, confidence in their preparation (

There were 3920 survey takers that responded to the question regarding in how many years they expected to retire; this was linked to how old they were at time of survey (

). From this information, we projected the time until retirement in a run chart over the next 25 years to illustrate that even though the mean age of this cohort of respondents was 60 years, the vast majority were considering retirement well beyond age 65 years. This figure also indicates that the majority of practitioners intend to retire 10 to 25 years from now.

We probed whether their PA specialty had some predictive measure on retirement. Family practice was the largest represented group in our survey respondents, followed by emergency medicine and general internal medicine. When sorted by specialty there was no correlation with retirement pattern (

Respondents were invited to submit comments about the questionnaire or to clarify answers. A total of 20 responded but only 4 comments were relevant to retirement preparation. Those comments are presented below:

“I am so glad to see this survey. I was wondering if I am the oldest PA practicing. I would love to connect with other PAs over 70 who are still practicing.”

“Are you eligible for a pension from your employer?!” “I have worked for 20 employers in the past 25 years. Some had contributed to my 401k pension plans, others matched a limited percent of contribution; others had none. Certainly consultant work is not pension-eligible. Rarely have profitsharing plans been used among my employers. Using the phrase ‘eligible for a pension plan’ sounds very old-fashioned and is a unique phrasing which seems irrelevant to contemporary retirement strategies.”

“I’m currently working as a contractor in Afghanistan and quite well enjoy the work, despite the fact I’m an ‘old guy.’ I’ve always loved my work, enjoy cross-cultural experiences, and enjoy any job involving travel. Have never considered retirement, as work keeps me ‘alive.’ My experiences in 40 years of medical work (paramedic, nurse, and PA) read like a National Geographic explorer’s tale and...well, why give it up?”

“Hey, I’m retiring from my current job but will continue to work as a PA at a part-time job. Please don’t delete me from your records, as I still want to maintain my NCCPA credentials.”

Intent-to-retire investigation is an activity of health workforce research and is an attempt to identify influencing factors on when this is likely to occur. It is a component of workforce modeling and retirement remains the major form of attrition of most professions. In studying retirement of health professionals, certain variables have more predictive value than others—for example, with physicians the gap between intent to retire and then actually retire decreases with age; the older one gets the more likely they will retire when they say they will.

 This was a pattern corroborated in our results. Roles have some predictive nature since physicians in the  surgical specialties tend to retire earlier than internal medicine specialties.

 We did not find any retirement intent correlation with age, gender, or specialty.

This study of clinically active PAs is an exploration of their retirement intent that builds on the work of Jones and colleagues (2006).

 Their study of PA preparedness for retirement was mixed. In the Jones study, gender variability was noted in several categories, and of particular concern was the finding that although 45% of female respondents would ideally like to retire under age 62 years (compared with 23% of males), 27% of females 55 years or older felt they could never afford to retire (compared with 8% of similar-aged males). The most important personal retirement decision factor of the PA faculty study was assurance of a satisfactory income (88%).

Turning to the results in our 2011 study the gender differences that emerged were that women reported less confidence in being prepared to retire. In the 4 leading questions about financial preparedness, having to retire suddenly, and healthcare preparedness, men consistently reported they were more confident or more prepared for retirement than women. The broad-based nature of the survey did not permit details but sets the stage for more refined work in this area.

Subjective comments by participants were broad in nature and permit some ideas to come through. While these for more ethnographic research on the nature of retirement and career decisions. Finally, our work agrees with the theory of planned behavior with anticipated career termination.

 The van Dam work suggests that employees’ retirement attitudes and perceived control over the retirement decision are related to early retirement intentions. Such results indicate that employees might postpone early retirement when they anticipate working in a challenging and rewarding work environment.

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Physician assistants are increasingly valued in health services access and delivery. Missing from predictive modeling has been the retirement rate.

Kim Brunisholz, MST

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Physician Assistants and Their Intent to Retire