Journal of the American Academy of Physician Assistants:
Gina M. Luckianow practices in the Department of Surgery at Yale New Haven Hospital in New Haven, Conn. Lewis J. Kaplan is chief of surgery at the Philadelphia VA Medical Center and an associate professor of surgery at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, Pa. The authors have disclosed no potential conflicts of interest, financial or otherwise.
Physician assistants (PAs) are bereft of a method of identifying clinical seasoning, educational accomplishment, and performance improvement project completion or research productivity in the hospital environment. Advanced practice nurses also are generally without an in-hospital rank advancement system. This absence stands in sharp contradistinction to nurses, who may commonly ascend a multilevel clinical ladder that denotes such achievements. Similarly, physicians in academic practice have a well-defined system spanning the entry rank of instructor through that of full professor. Physicians who are not connected to a medical school have no such ranking scheme, but generally do not seek nor perceive the need to embrace an academic rank.
Academic physicians generally work to advance their rank on the basis of clinical service coupled with education and/or clinical investigation (common) or on the basis of basic science research endeavors (less common). The benefits of advanced rank are numerous and spur physicians to pursue additional educational or research success. Benefits may include a greater guaranteed salary base, reduced clinical exposure, enhanced meeting attendance and travel capacity, and enhanced service opportunities within the physician's system as well as in national or international professional societies.
Without a parallel recognition and reward structure, what driving force exists for PAs to undertake additional education or to participate in clinical or basic science investigation? While one might cite personal motivation and internal drive, most PAs function in an hours-based role (work is tied to a set number of hours), rather than professional capacity (work is tied to task completion regardless of hours; the system most commonly used by physicians). Therefore, PAs generally will need to pursue investigative or performance improvement efforts outside of their allotted shift–a time encumbrance that is not rewarded under the current structure. Outside of satisfying CME requirements, professional society attendance generally is not used as a springboard for academic creativity. Relatedly, working to present the derived data at a national forum may be viewed as unnecessary and erosive of personal time instead of as a professional goal.
One can envision a system (like that of many inpatient facility nurses) that lets PAs begin at the first rung of a multistep ladder. Advancement up the ladder can be tied to measurable elements such as publishing a case report or review article; performing a unit or service-based performance improvement project; collaborating in a clinical research project; presenting at a local, regional, or national conference; or obtaining an advanced degree. Each rung of the ladder could provide increased salary, an augmented travel budget, increased schedule control, and other benefits that would be compatible with the hospital's resources and needs.
An apex rung could be set, providing additional benefits that might be uniquely desirable for PAs and not solely reflective of, but in concert with, hospital goals. For instance, apex-rung PAs might want to acquire airway control skills and would be allowed to have daytime shift hours spent in the OR garnering those skills, instead of working in their typical units or with their typical teams. Such skills acquisition meets a personally motivated need but also benefits the hospital, especially for PAs who are part of a rapid response team.
In conclusion, we have highlighted a disparity between hospital-based employees with regard to a professional advancement mechanism. Having a clearly identifiable and objectively measurable goal-oriented ladder scheme to denote and encourage professional development would help to span this gap for PAs.