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Letters to the Editor

Formal Training for Practice: How Much Is Too Much?

Cawley, James F. MPH, PA-C

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doi: 10.1097/ACM.0000000000003362
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To the Editor:

In his editorial, Sklar,1 commenting on the Perspective by Dewan and Norcini,2 notes that physician assistants (PAs), nurse practitioners (NPs), as well as medical students require additional supervised clinical experiences to attain practice competency. For PAs and NPs, experience and competency are attained through the apprenticeship model working with experienced physicians. As noted, this training difference clouds comparisons of PA and NP versus physician clinical capability. The existing health services literature suggests that PA and NP care is indistinguishable from physician care, but it is difficult to determine how much their clinical performance reflects their formal training and how much reflects their on-the-job experience.

There are a growing number of PA and NP postgraduate training programs—as of 2020, there were 99 PA postgraduate programs spanning 26 clinical disciplines3 and 76 NP postgraduate programs.4 Most of these programs are 1-year inpatient-based experiences sponsored by academic health centers and health systems and do not, as yet, have formal accreditation or standardization. With a few exceptions, academic credentials are not awarded, and the trainee stipend is far below the salary of a comparable graduated practitioner. Only some are in primary care.

In addition to the development of PA and NP residencies, there is also a trend of shortening physician education for primary care practice.5 I suggest that future research examining educational and apprenticeship preparation for primary care take these differences into consideration. In thinking of formal training for practice, perhaps one is too long and the other too short—but by how much?

James F. Cawley, MPH, PA-C
Professor, School of Physician Assistant Practice, Florida State University, Tallahassee, Florida, and visiting professor and scholar-in-residence, University of Maryland, Baltimore, Baltimore, Maryland;


1. Sklar DP. Training models for physician assistants and nurse practitioners: Disruptive innovations that could improve health professions education and practice. Acad Med. 2019;94:917–920.
2. Dewan MJ, Norcini JJ. Pathways to independent primary care clinical practice: How tall is the shortest giant? Acad Med. 2019;94:950–954.
3. Association of Postgraduate APRN Programs. Association of postgraduate PA programs. Accessed March 16, 2020.
4. Association of Postgraduate APRN Programs. Program master list. Updated February 26, 2020. Accessed March 16, 2020.
5. Abramson SB, Jacob D, Rosenfeld M, et al. A 3-year M.D.–accelerating careers, diminishing debt. N Engl J Med. 2013;369:1085–1087.
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