doi: 10.1377/hlthaff.2009.0884 HEALTH AFFAIRS 29, NO. 5 (2010): 880 886 2010 Project HOPE The People-to-People Health Foundation, Inc. By Roderick S. Hooker, James F. Cawley, and William Leinweber DataWatch Career Flexibility Of Physician Assistants And The Potential For More Primary Care Roderick S. Hooker (Roderick.Hooker@va.gov) is an adjunct professor in the School of Public Health, University of North Texas Health Sciences Center, and the Department of Veterans Affairs in Dallas, Texas. James F. Cawley is professor and director of the physician assistant program at the School of Public Health and Health Services, George Washington University, in Washington, D.C. William Leinweber is executive vice president of theamericanacademyof Physician Assistants in Alexandria, Virginia. ABSTRACT In part because of their core generalist education, physician assistants can change clinical specialties over the course of their work life. This is known as career flexibility. Using medical care providers who can adapt quickly to new opportunities could help alleviate medical workforce shortages in primary care. We studied annual surveys undertaken by the American Academy of Physician Assistants to determine how many physician assistants changed specialties and how frequently. Over four decades, 49 percent of all clinically active physician assistants changed specialties sometime in their careers. This suggests that incentives, such as educational grants, could draw more physician assistants to work in primary care. These findings suggest that an array of new incentives under health reform could draw and retain more physician assistants into primary care medicine. Physician assistants (PAs) are able to change clinical specialties over the course of their work life, an attribute termed career flexibility. In the United States, the ability of physician assistants to change specialty contrasts with the situation of physicians and nurse practitioners, who, once trained, tend to be bound to one specialty. When the PA profession was developed in the 1960s, its creators had in mind generalist-trained assistants to work closely with physicians. 1 This generalist preparation and relatively short period of training enabled physician assistants to respond to marketplace demand in various medical and surgical roles. The nation arguably faces looming shortages of doctors and nurses a problem that could be made worse by such factors as the aging of the population. 2,3 Primary care is seen as a particularly critical area. Fewer medical graduates are selecting family medicine each year. 4 For the United States as a whole, the number of ambulatory visits is increasing, exceeding one billion in 2005. 5 The domestic production of physicians is unlikely to meet the population s demand for services, at least not in the short run. 6 On top of these factors, there is growing evidence that a multidisciplinary team-oriented workforce, similar to those seen in certain managed care systems, is a principle of organizational efficiency. 7 Using medical care providers who can adapt quickly to new opportunities could conceivably help fill medical workforce vacancies in specific areas, such as primary care. In a highly capitalized system that values choice and economic influences, we wondered how many physician assistants switch from one specialty to another, and how often they do so. An adaptable medical workforce that can shift from a specialty in low demand to one in high demand would permit greater responsiveness to medical services needs. Because PAs ability to change specialties has not been quantified, we set out to describe this characteristic. Our research centers on one question: What degree of flexibility in specialty roles occurs over the course of a physician assistant s career? 880 HEALTH AFFAIRS MAY 2010 29:5
Study Data And Methods Data Source Data on the specialty mix of physician assistants have been collected in annual census surveys undertaken by the American Academy of Physician Assistants (AAPA) since 1990. The census asks all PAs to respond to a set of questions about current employment setting and practice specialty, income, and other characteristics. This survey has been described elsewhere in greater detail. 8 Census information on specialty is used to update the AAPA s database of all graduates of PA programs from 1967 through 2008. Use of this database allows inclusion of both participants and nonparticipants in the census. Methods For clarification, an annual census collection is referred to as the census reference year. All physician assistants who graduate in one year are referred to as a graduation year cohort. Primary care is defined as general pediatrics, general internal medicine, and family medicine. The PA census reference year was further divided into two groups: (1) established graduates, defined as PAs who were in the profession more than one year after graduation; and (2) new graduates, defined as PAs who entered the profession in the year immediately preceding the census reference year. New PA graduates are distinguished from established PAs for cohort analysis. A cohort consists of all physician assistants defined by the year of graduation. The sixty-four specialty options on the census questionnaire were aggregated into one of eleven classes, including family practice, surgery, and medical specialties. To examine specialty change by members of different graduation-year cohorts, we noted when the specialty change took place.we wanted to know whether PAs, upon declaring one specialty, reported a specialty change and, if so, how much time lapsed before they did. An essential question regarding PAs flexibility concerns the nature of specialty changes (not including geographical change). Interspecialty change versus intraspecialty change needs to be distinguished if the true nature of change is to be understood. Two distinctions were made. In an intraspecialty change, a physician assistant changed specialties within a class, such as orthopedics, to another related specialty such as hand surgery. An interspecialty change was moving from one specialty class to another, such as from pediatrics to emergency medicine. Statistical Analysis The AAPA database identified all physician assistants who ever graduated from a PA program. This research population of interest was sorted by the following methods: (1) the number and percentage distribution of physician assistants by specialty, 1991 2008; (2) the number of times a specialty was reported by physician assistants (per cohort); (3) the percentage and number of times a distinct specialty class was reported on the census; (4) the percentage and number of respondents in each cohort by the number of lapsed years between the first and second specialties; and (5) the percentage and number of PAs in the first reported specialty by the second reported specialty. Attrition due to death, retirement, leaving the profession, or simply loss to follow-up was not part of this analysis, but these factors also contribute to the diminishing rate of return. Study Results As of January 2008, the total number of individuals who ever graduated from a U.S. physician assistant program was 80,688. Each graduation year of PAs was defined. The first cohort of PAs numbered three in 1967; the forty-second cohort numbered 5,609 in 2008. In the aggregate, 51 percent of all PAs reported only one specialty in their career, regardless of duration. Of those who reported more than one specialty over a career (49 percent), one-fifth of switchers reported at least three unique specialties. However, during the first two decades after the position of PA came into being, the profession was predominantly composed of older men who had relatively shorter careers than those in the latter two decades. Thus, to better understand recent patterns of specialty change, we isolated the latest seventeen years of data (1991 to 2008) and subjected these to further analysis. Physician Assistants Specialty Choices Exhibit 1 shows the proportional annual distribution of all PAs, by specialty, from 1991 to 2008. A shift in specialty distribution during this period marks a drift away from the primary care specialties. The percentage of PAs in family medicine grew to 40 percent during 1991 1996 and declined to 27 percent in 2008. Conversely, the percentage of PAs in surgery, including subspecialties, was 16 percent in 1995 and gradually increased to 27 percent in 2008. When Specialty Shifts Occur The period when specialty change is likely to occur was examined from 1991 to 2006. One-third, or 32 percent, of established graduates who reported a second distinct specialty did so one year after reporting their first specialty. An additional 19 percent reported a second distinct specialty within two years after the first report. Overall, the mean number of years that passed between the first and second reports of a distinct MAY 2010 29:5 HEALTH AFFAIRS 881
EXHIBIT 1 Distribution Of All Physician Assistants, By Specialty, 1991 2008 Percent Family practice Surgical subspecialties Internal medicine subspecialties Emergency medicine General surgery General pediatrics SOURCE American Association of Physician Assistants Membership Census Surveys, various years. specialty change is 3.5 years. When the data are examined by cohort year, the median is two years, and the trend has declined from 3.9 years to one year over the same period (Exhibit 2). The new-graduate cohort revealed a similar pattern over the same period as for established graduates. Since 2000, newly graduated PAs are switching specialties sooner than those in the past. In this more recent period, 30 36 percent reported changing to their second distinct specialty one year after reporting their first specialty. A subanalysis of all graduates over the seventeen years identified that many of the changes were intraspecialty, or from one specialty to a related specialty. For example, of the PAs whose first reported specialty was general surgery, 46 percent reported a surgical subspecialty if a EXHIBIT 2 Mean Number Of Interval Years When Changing From One Specialty To A Different Specialty, By Physician Assistant Graduation Cohort, 1991 2006 Interval years (mean) PA graduation-year cohort SOURCE American Association of Physician Assistants Membership Census Surveys, various years. 882 HEALTH AFFAIRS MAY 2010 29:5
second specialty was reported. PA Specialty Classes Change within the eleven distinct specialty classes was examined for interspecialty trends. Exhibit 3 presents information about the first and second specialties reported, by specialty class. Distinct specialty changes are seen moving from one area of specialty to another. Almost half, or 47 percent, of family medicine PAs reported a second specialty for example, emergency medicine. Conversely, 19 percent of physician assistants in emergency medicine and 25 percent of those in occupational medicine reported family medicine as their second specialty. Similar patterns were observed for general internal medicine. Ten-Year Trends We sought to understand the number of opportunities that a member of any cohort by graduation year could have had to report a specialty change. Doing so required selecting only those who responded to the AAPA census survey for ten years or longer in the 1991 2008 period of observation. An absence of one year dropped the subject from this ten-year trend analysis. Within this more refined group of PAs, the number of specialties reported was confined to the number of census surveys in which a specialty was reported. If a specialty designation was omitted from any consecutive census, the subject was dropped from the analysis. One-fifth of the 45,826 PAs who participated in multiple census surveys participated in ten or more consecutive surveys. A quarter of this group, or 26 percent, reported one or more interspecialty switches. Cohort Analysis To standardize the time in a cohort, we examined the prevalence of changes in specialty by physician assistants who participated in census surveys in consecutive years from graduation to the next year. Because of the consistency of the survey instrument used from year to year, we were able to reliably create a large set of PA cohorts that could be tracked and compared between 1991 and 2008. The findings rely on the assumption that there is no relationship between a physician assistant s participation in a census survey and a change of specialty. Depending on the year of graduation, 12 25 percent of physician assistants who participated in two or more consecutive census surveys reported working in two specialties that were either related or different (Exhibit 4). Consecutive survey respondents represent the most reliable data for projecting the likelihood of PAs career flexibility. Discussion Key Findings Spanning four decades, 49 percent of all clinically active physician assistants changed specialties sometime in their careers. In addition, among the almost half of physician assistants who switched specialties, 24 percent switched to a different specialty class. This adaptability holds important implications for workforce policy and the implementation of incentives. It confirms that PAs are mobile and able to change jobs to respond to strong demand for their services in the medical marketplace. From an employer s standpoint, skill mix and EXHIBIT 3 Percentage Distribution Of Physician Assistants In First Reported Specialty, By Percentage Of Those Who Reported A Second Specialty At Some Time In Their Career No change FP GIM Emerg GPED GSURG IMsub PEDsub SURGsub OB OM Other Total Total 51 9 6 6 1 2 6 1 7 1 2 8 100 FP 53 9 10 2 1 5 1 6 2 3 9 100 GIM 30 22 5 1 1 19 1 5 1 2 13 100 Emerg 52 19 4 1 1 3 1 8 1 3 6 100 GPED 49 17 3 4 1 3 12 5 1 1 5 100 GSURG 28 6 3 5 0 4 0 46 1 1 5 100 IMsub 52 9 11 4 1 1 3 7 1 1 11 100 PEDsub 43 8 3 5 13 1 8 8 2 1 8 100 SURGsub 67 6 2 5 0 7 5 1 1 1 6 100 OB 53 18 4 3 1 3 4 2 5 1 7 100 OM 37 25 6 8 0 1 4 1 8 1 9 100 Other 48 16 8 3 1 2 10 1 9 1 2 100 SOURCE American Association of Physician Assistants Membership Census Survey. NOTES All rows might not add to 100 because of rounding. FP is family practice. GIM is general internal medicine. Emerg is emergency medicine. GPED is general pediatrics. GSURG is general surgery. IMsub is internal medicine subspecialty. PEDsub is pediatric subspecialty. SURGsub is surgical subspecialty. OB is obstetrics/gynecology. OM is occupational medicine. MAY 2010 29:5 HEALTH AFFAIRS 883
EXHIBIT 4 Changes In Physician Assistant Specialty, By Graduation-Year Cohort, 1991 2006 No change Interspecialty change Intraspecialty change Percent SOURCE American Association of Physician Assistants Membership Census Survey, various years. career elasticity permits shifts of labor resources from one area to another in times of demand surges. Such malleable skills are embodied in the staffing systems of the uniformed services, the Veterans Health Administration, and other vertically integrated civilian medical care systems, where demand is not always linear or predictable. 9,10 We posit that the generalist medical education model of PAs enables them to change specialties over the course of their careers. Career change may be attributable to medical staffing demands, availability of positions, promising employment opportunities, or emerging economic forces. For example, in 2008 there were approximately 7,400 clinically active PAs in emergency medicine, where both burnout and turnover are high. 11 Because physician assistants are not locked into one role, career flexibility permits them to move from a highly stressful job to a job with less stress, thus retaining their skills in the medical labor pool. Such flexibility has also permitted PAs to develop roles in inpatient care substituting for physician residents who are limited by work-hour restrictions. 12 Helping Fill Workforce Shortages Understanding the nature and prevalence of PAs flexibility may be useful as shortages in certain specialties emerge. 4 Beginning in the early 1990s, it was generally accepted that the supply of primary care providers needed to expand. During this period, the number of PAs in family medicine increased, which suggests that the specialty distribution of the PA workforce was influenced by the need for primary care. During the period of the 1970s through the 1990s, grants issued under Title VII of the Public Health Service Act for PA program support were considered a key factor in growing the PA profession with a focus on primary care. 13 Because the new century saw a sharp decline in Title VII grants available for PA programs, training emphasis on primary care declined as well. Study Limitations Theoretically, the true number of employment changes a person makes can be counted only after the career has ended. This poses challenges in career analysis research, because the PA profession is relatively young. Four-fifths of all physician assistants have graduated since 1990, and the average age is 42 years. Data on the determinants of PAs specialty preference showing higher salaries in the surgical specialties indicate that economics, in the aggregate, probably influences specialty choice more than any other single factor. 14 Because of the broad nature of this workforce investigation, a number of nested variables in career selection were set aside. Age, sex, geography, opportunity cost such as education debt, stated race, and ethnicity are important individual characteristics for role selection but were beyond the focus of our population-based 884 HEALTH AFFAIRS MAY 2010 29:5
Health workforce policies aimed at taking advantage of PAs clinical flexibility could be given greater consideration. research. Conservative assumptions were used throughout this analysis, opening up the possibility that the degree of change may be different than reported. Not all sixty-four PA specialties were represented because of low numbers, such as in psychiatry, radiology, forensic medicine, and anesthesia. The annual census may not capture new specialties. For example, hospital medicine was not added to the census until 2009 but was historically included as general internal medicine. 12 Although this analysis takes advantage of a unique database that captures all members of a profession from the onset, it has the limitations of breadth over depth. The nature of specialty change is difficult to assess because it incorporates behavior, choice, opportunities, and other externalities over the course of a career. However, since the mid-1990s the market for PAs has been robust; salary growth exceeds inflation, choices are plentiful, and benefits are generous. 8 At the same time, economic labor analysis on physician assistants is hampered by the lack of a defined cohort that is periodically surveyed. Longitudinal research that captures data such as role delineation, social pressures, economic events, family structure, and other influences is critical for understanding important career selection variables. Conclusion Physician assistants exercise a fair amount of career flexibility. At least half change their specialty once in their career. A quarter will practice at least two different specialties, and at least 11 percent will work in three or more different specialties over the course of their careers. Hospitals, large managed care organizations, the Department of Defense, the Veterans Health Administration, and other institutions have used these PA characteristics in staffing medical and surgical services for more than four decades. Although family medicine remains the largest single PA specialty, it is one in which shifts are occurring the most. Since the late 1990s, the net number of PAs departing family practice exceeds the number moving into this area of medicine. Furthermore, each year a smaller percentage of PAs select family medicine upon graduation. We suggest that salary differentials may be the main influence on this migration effect, along with new role opportunities in the broadening spectrum of medicine. 14 Popular specialty choices for physician assistants include emergency medicine, dermatology, orthopedics, cardiovascular medicine, and the internal medicine subspecialties. An expected finding was that among PAs whose original specialty was surgery, nearly half of those who changed specialties chose a surgical subspecialty. An unexpected finding was that primary care was attracting some physician assistants out of specialty roles. Such observations suggest that this career flexibility is more fluid than suspected and is probably subject to a wide range of influences. One theory explaining the patterns of PAs career mobility is the generalist education core. PA educational programs teach the full spectrum of general medicine to prepare graduates to enter many specialty roles in both primary and nonprimary care. Along the career path, PAs may shift their focus based on availability. The physician assistant sees an abundant job reservoir and makes choices based on factors such as location, salary, and specialty of interest. The obverse side of the career mobility coin is career stability. At least half of all PAs remain in their first chosen specialty throughout their careers, with primary care at the top of the list. This staying power in one career is well established throughout health care but has not been described in any systematic way for physician assistants. PAs were originally intended for primary care roles, but market forces specifically, higher salaries have drawn many to specialty practice. PAs adaptability suggests that policy initiatives could be implemented to address medical workforce shortages, especially in primary care. Health workforce policies aimed at taking advantage of PAs clinical flexibility, such as offering educational grants to both individuals and institutions as an incentive to work in primary care as well as rural and underserved areas, could be given greater consideration. At one time, such strategies produced impressive results in the deployment of PAs to medically underserved communities and in generalist practice. 13 We suggest that meeting demand for primary care providers, including physician assistants, MAY 2010 29:5 HEALTH AFFAIRS 885
will require greater incentives. One notion is for military-trained PAs to move to civilian roles with financial incentives for them in primary care and rural practice. The trading of obligated work time for tuition forgiveness has been well tested over decades. In summary, we believe that PAs career flexibility holds workforce potential in a reformed health care system where more primary care personnel are needed. TheauthorsthankKevinMarvelle, former research director of the American Academy of Physician Assistants, for making these data available. The contributions of Tim Dall, Perri Morgan, and an anonymous reviewer substantially improved the overall quality of the manuscript. The authors have no disclosures or disclaimers. No funding was obtained for this project. NOTES 1 Hooker RS, Cawley JF, Asprey DP. Physician assistants: policy and practice. Philadelphia (PA): FA Davis; 2010. 2 Colwill JM, Cultice JM, Kruse RL. Will generalist physician supply meet demands of an increasing and aging population? Health Aff (Millwood). 2008;27(3):232 41. 3 Cooper RA. New directions for nurse practitioners and physician assistants in the era of physician shortages. Acad Med; 2007;82:827 8. 4 Goodman D, Grumbach K. Does having more physicians lead to better health system performance? JAMA. 2008;299:335 7. 5 Burt CW, McCaig LF, Rechtsteiner EA. Ambulatory medical care utilization estimates for 2005. Hyattsville (MD): National Center for Health Statistics; 2007. 6 Mullan F. Testimony at: Workforce Issues in Health Care Reform: Assessing the Present and Preparing for the Future: Hearings before the Senate Committee on Finance. 111th Cong, 1st sess. (2009). 7 Jacobs R, Smith PC, Street A. Measuring efficiency in health care: analytic techniques and health policy. Cambridge (UK): Cambridge University Press; 2006. 8 American Academy of Physician Assistants. Physician assistant census report. Alexandria (VA): AAPA; 2008. 9 Hooker RS. 2008. Federally employed physician assistants. Mil Med. 2007;173:895 9. 10 Association of Academic Health Centers. Out of order, out of time: the state of the nation s health workforce.washington (DC): AAHC; 2008. 11 Bell RB, Davison M, Sefcik D. A first survey: measuring burnout in emergency medicine physician assistants. J Am Acad Physician Assist. 2002;15(3):40 2. 12 Cawley JF, Hooker RS. The effects of resident work hour restrictions on physician assistant hospital utilization. Journal of Physician Assistant Education. 2006;17:41 3. 13 Cawley JF. Physician assistant and Title VII support. Acad Med. 2008; 83:1049 56. 14 Morgan PA, Hooker RS. Choice of specialties among physician assistants in the United States. Health Aff (Millwood). 2010;29(5):887 92. 886 HEALTH AFFAIRS MAY 2010 29:5