Does Community College Attendance Affect Matriculation to a Physician Assistant Program? A Pathway to Increase Diversity in the Health Professions : Academic Medicine

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Does Community College Attendance Affect Matriculation to a Physician Assistant Program? A Pathway to Increase Diversity in the Health Professions

Luo, Qian MPSA, PhD1; Erikson, Clese E. MAff2; Chitwood, Ryan MS3; Yuen, Cynthia X. MA4

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Academic Medicine 97(1):p 121-128, January 2022. | DOI: 10.1097/ACM.0000000000003860


Increasing the diversity of the workforce is a priority and a challenge for all health professions. Fostering a diverse workforce depends on first recruiting and retaining diverse students, a process that has been slow in the physician assistant (PA) profession. For instance, the percent of White matriculants to PA programs increased from 77% in academic year (AY) 2002–2003 to 82% in AY 2012–2013, while the percent of Black matriculants decreased from 6% to 4%. 1 This time frame coincided with a period of marked expansion in the number of PA programs, nearly all of which awarded a master’s degree to graduates. 2 The transition to PA programs awarding a master’s degree began in the early 2000s, with the accrediting body for the PA profession mandating that all programs do so by 2021. 3 Concerns were raised that this transition would become a barrier to entry for minority students, 4 and it has heightened the need to identify strategies to increase the recruitment of minority students to PA programs. In response, multiple programs have modified their admissions interview processes to increase the diversity of their accepted students. 5 Programs also use pipeline systems to attract greater numbers of qualified minority applicants to the profession earlier in their education. 6

Community colleges (CCs) are an important port of entry to higher education for minority students and those from rural and lower socioeconomic status (SES) backgrounds. Across all higher education degrees, approximately half of Black and Hispanic students begin their college education at a CC, compared with 36% of White students, 7 and approximately half of rural students begin their college education at a CC. 8 Furthermore, half of CC students have a family income of less than $50,000. 9 Similarly, a 2014 study conducted by Talamantes and colleagues found that 28% of medical school matriculants had a history of CC attendance and that those students were more likely to be Black or Hispanic or to be the first in their family to attend college than students with no-CC background. 10 In addition, the same study found that these students may face discrimination in the admissions process. For example, CC students had lower acceptance rates to medical school than those with no-CC background, even after controlling for race and ethnicity, Medical College Admission Test score, and grade point average (GPA).

Given the challenges that the PA profession faces in increasing its diversity and evidence that CCs attract a more diverse pool of students, it is important to examine the pathways that CC students take to a PA program. Thus, we extended the analysis conducted by Talamantes and colleagues 10 to PA programs. We sought to answer 2 research questions: (1) Are CC applicants a significant contributor to the racial, ethnic, rural, and/or SES diversity of matriculants to PA programs? and (2) Are CC applicants less likely to matriculate to a PA program than students with no-CC background?



The Physician Assistant Education Association (PAEA) administers the Central Application Service for Physician Assistants (CASPA), 11 a web-based application system that collects detailed applicant information, including where applicants matriculated if accepted. In this study, we used data from the 2016–2017 CASPA application cycle, during which time the system was used by 219 (95%) accredited PA programs in the United States.

We analyzed the following variables: demographics (e.g., age, gender, race, ethnicity, rurality), prior education experience and performance (e.g., high schools, higher education institutions, undergraduate science GPA, baccalaureate total GPA), Graduate Record Examination (GRE) score percentiles, SES (e.g., whether the applicant’s family was economically disadvantaged), and application status (e.g., programs to which the applicant applied and, when applicable, matriculated). All demographic and SES variables were self-reported by applicants (see Supplemental Digital Appendix 1 at for details). CASPA verifies GPAs and coursework against official transcripts from higher education institutions. The system also requires that applicants report all courses in their application, including courses from which they withdrew, repeated courses, ungraded labs, test credits, gym courses, orientations, and other nongraded courses. The Educational Testing Service, which produces the GRE, directly transmits official GRE scores and percentiles to CASPA.

Data were available for 25,443 applicants, 8,557 (34%) of whom ultimately matriculated to a PA program. PAEA linked the PA programs and the Carnegie Classification of Institutions of Higher Education codes (see Supplemental Digital Appendix 2 at and then deidentified the dataset, before releasing it to the research team.

Defining the CC pathways

Following Talamantes and colleagues, 10 we determined applicants’ CC pathway using the Carnegie Classification of Institutions of Higher Education codes. 12 We used 4 different versions of the Carnegie Classification codes to define 5 CC pathways depending on the applicant’s year of graduation from the higher education institution: (1) HS-CC (applicant attended a CC while in high school), (2) first-CC (applicant attended a CC before a 4-year university), (3) 4Y-CC (applicant attended a CC while at a 4-year university), (4) post-CC (applicant attended a CC after graduating from a 4-year university), and (5) no-CC (applicant never attended a CC). This 5-category pathway variable was our primary independent variable of interest. See Supplemental Digital Appendix 2 at for a detailed description of our CC pathway classification methodology.

The rationale for creating different CC pathways instead of a single dummy variable for CC applicants is grounded in the different motivations of applicants in the different pathways. 10 For example, HS-CC students primarily used CC for an accelerated academic track that helped them gain acceptance to a more competitive 4-year university. First-CC students were the traditional CC students who obtained an associate’s degree then pursued a 4-year university. 4Y-CC students usually took a few courses at a nearby CC while completing a 4-year university degree. Post-CC students often took some courses at a CC after completing a 4-year university degree to satisfy PA program admission prerequisites, which differ significantly across the country. 13

In our sample, 5,826 (23%) applicants and 1,899 (22%) matriculants used more than 1 CC pathway. We assigned these individuals to a single CC pathway based on the following stepwise algorithm: (1) students with any CC background before a 4-year university were categorized as first-CC regardless of their other CC experiences; (2) the remaining students with a CC background after completing a 4-year university were categorized as post-CC; and (3) the remaining students with both HS-CC and 4Y-CC backgrounds were categorized as HS-CC.

Data analysis

To determine whether CC applicants were a significant contributor to the racial, ethnic, rural, and/or SES diversity of matriculants to PA programs, we compared race and ethnicity, SES, and rurality among matriculants in the different CC pathways. For categorical variables, we used Pearson chi-square tests followed by pairwise Pearson chi-square post hoc tests to compare matriculants in the 4 CC pathways and those in the no-CC pathway. 14 For continuous variables, we used Kruskal-Wallis H tests followed by Conover-Iman post hoc tests to conduct pairwise comparisons between matriculants in the 4 CC pathways and those in the no-CC pathway. 15 We applied a Bonferroni correction to P values for all post hoc tests.

To determine whether CC applicants were less likely to matriculate to a PA program than no-CC applicants, we conducted a binary logistic regression using matriculation as the outcome and CC pathway as the primary independent variable of interest. We controlled for other covariates, including (1) applicants’ race, ethnicity, age, and gender; (2) undergraduate academic performance (e.g., undergraduate science GPA and baccalaureate total GPA); (3) standardized test performance (e.g., GRE score percentiles for the Quantitative Reasoning, Verbal Reasoning, and Analytical Writing sections); (4) application strategy (e.g., number of applications submitted and the relative competitiveness of the least competitive school to which the applicant applied); and (5) rurality (geographic area of hometown) and SES (self-reported data of coming from an economically or environmentally disadvantaged background). See Supplemental Digital Appendix 1 at for a detailed description of all covariates. We used heteroskedasticity-consistent standard errors to determine confidence intervals and statistical significance.

We used Stata (version 15/MP, StataCorp, College Station, Texas) for all analyses. The George Washington University Office of Human Research determined that this study was exempt from institutional review board review.


Table 1 presents a breakdown of applicants and matriculants in each CC pathway by demographic and other variables as well as the results of the Pearson chi-square and Kruskal-Wallis H tests followed by the results of the corresponding post hoc tests on pairwise differences between matriculants in the 4 CC pathways and those in the no-CC pathway. Among the 8,577 matriculants in the 2016–2017 CASPA application cycle, more than 75% attended a CC at some point: 2,313 (27%) in the HS-CC pathway, 1,079 (13%) in the first-CC pathway, 1,231 (14%) in the 4Y-CC pathway, and 1,825 (21%) in the post-CC pathway.

Table 1:
Differences in Demographics, Academic Performance, Rurality, and Socioeconomic Status Between Applicants and Matriculants to Physician Assistant Programs by Community College Pathway, 2016–2017

The Pearson chi-square tests showed that the differences in demographic and other variables between matriculants from the different CC pathways were statistically significant (P < .01) for all but the other race variable (P = .72), indicating that matriculants from the different CC pathways differed in their demographic and other characteristics. Pairwise post hoc tests allowed us to assess the differences between matriculants in the no-CC pathway and those in the 4 CC pathways. Most notably, these tests indicated that, compared with matriculants in the no-CC pathway, those in the first-CC and post-CC pathways were significantly more likely to be Black (P < .001) or Hispanic (P < .001), to come from an urban area (P = .02), and to have a disadvantaged SES status (P < .001). Additionally, matriculants in the first-CC, 4Y-CC, and post-CC pathways had lower undergraduate science GPAs and baccalaureate total GPAs than those in the no-CC pathway (P < .001).

To investigate whether the likelihood of matriculation significantly differed among applicants in the various CC pathways, we ran 5 logistic regressions with different control variables; adjusted odds ratios from the full model are presented in Table 2, and detailed results are shared in Supplemental Digital Appendix 3 at After adjusting for demographics, application strategy, academic performance, and rurality and SES, first-CC applicants had 17% lower odds of matriculating to a PA program than no-CC applicants (P < .001, see Figure 1). We found no statistically significant differences in the odds of matriculation among HS-CC, 4Y-CC, and no-CC applicants. Interestingly, post-CC applicants had 13% greater odds of matriculating to a PA program than applicants in the no-CC pathway (P = .01). Asian applicants had 27% lower odds of matriculation (P < .001), while Hispanic applicants had 17% greater odds of matriculation (P = .007), than non-Hispanic White applicants, adjusting for all other factors. SES characteristics and rural background were not significantly associated with matriculation status (see Table 2).

Table 2:
Adjusted Odds Ratios for the Likelihood of Matriculation to a Physician Assistant Program by Demographic and Other Variables, 2016–2017
Figure 1:
Adjusted odds ratios for the likelihood of matriculation to a physician assistant (PA) program for applicants with a community college (CC) background compared with those with no-CC background, 2016–2017. Abbreviations: no-CC, applicant never attended CC; HS-CC, applicant attended CC while in high school; first-CC, applicant attended CC before a 4-year university; 4Y-CC, applicant attended CC while at a 4-year university; post-CC, applicant attended CC after graduating from a 4-year university.

Application strategy also played an important role in matriculation. Adjusted for all other factors, each additional application submitted was associated with 9% greater odds of matriculation (P < .001). In addition, the relative competitiveness of the programs to which applicants applied (described in Supplemental Digital Appendix 1 at mattered. Applicants who applied to only the most competitive programs were 5 times less likely to matriculate to a PA program (P < .001) than those who applied to less competitive programs. Academic performance was also an important factor in matriculation. Each 0.1 increase in undergraduate science GPA and baccalaureate total GPA was associated with 30% and 10% greater odds of matriculation, respectively (P < .001). Similarly, every 5% increase in GRE Quantitative Reasoning, Verbal Reasoning, and Analytical Writing scores was associated with greater odds of matriculation (5%, 4%, and 3% respectively; P < .001). Applicants who did not have a GRE score had 19% lower odds of matriculation than applicants with an average GRE score (P < .001). Rurality and SES variables had no statistically significant relationship with the odds of matriculation (see Supplemental Digital Appendix 3 at

For robustness checks, we included the 1,300 applicants who were missing at least 1 GPA by imputing their existing GPAs and generating dummy variables for their missing GPAs. The results were substantively similar, suggesting that the missing GPAs did not significantly affect our results. See Supplemental Digital Appendix 4 at for these results.


In the AY 2016–2017 application cycle, CCs represented a major pipeline for PA programs, with 3 of 4 matriculants having a CC background. This proportion of matriculants was much higher in PA programs than MD programs. 10 Consistent with a similar study of medical school matriculants, we found that applicants to PA programs with a CC background, versus those without, were more racially, ethnically, and socioeconomically diverse. Therefore, admitting more students with a CC background, particularly first-CC students, may increase the diversity of the PA student body and, subsequently, the profession.

We also found that when other important factors, such as academic performance, demographics, and application strategy, were equal, those students who attended a CC as their first entry into higher education following high school were 17% less likely to matriculate to a PA program than those students without a CC background. This raises the possibility that some bias, whether conscious or unconscious, may exist against applicants who attended a CC before pursuing a 4-year university degree. If indeed this is the case, PA programs might be unintentionally limiting their ability to recruit racial/ethnic minority, rural, or socioeconomically disadvantaged students, who tend to be more interested in careers in primary care and practicing in rural and underserved communities, where additional health professionals are needed. 11,16–18 PA programs also may be missing out on the attendant benefits that a diverse student body provides, including more well-rounded graduates who are better prepared to care for a diverse population. 19 Focusing on strategies to increase diversity through the CC pipeline has the additional benefit of relative immediacy as these potential candidates are only a few years from being eligible to apply to PA programs.

Our study reveals an opportunity for the PA profession to reevaluate how programs factor a CC background into admissions decisions and whether admission policies and requirements potentially discriminate against or otherwise create barriers for CC applicants. Adopting a more holistic admissions process could present a ripe opportunity for PA programs to increase the number of successful CC applicants, thereby enriching the racial, ethnic, and SES diversity of the profession and promoting health equity. 20 Another strategy to ensure an equitable admissions process is to include on admissions committees individuals trained in implicit bias and diverse patients and/or community members. 21 However, as the number of applications to PA programs continues to increase, there are concerns that applicants with lower GPAs and GRE scores, which are traditional application metrics, will be screened out before getting to the holistic review step in the admissions process. 20 This could particularly affect first-CC applicants, who we identified as having significantly lower GRE scores on average than no-CC applicants.

Given that CC applicants (with the exception of HS-CC applicants) had lower undergraduate science and baccalaureate total GPAs than those with no-CC background, PA programs might consider engaging more with students at local CCs, with the goal of enhancing the academic preparation of prospective applicants. 22 This approach has proven successful for nursing programs and could hold potential for the PA profession. 23,24 For example, PA program faculty could serve as guest lecturers or host “brown bag” lunches to showcase the profession and make sure that prospective students have a strong understanding of how to be a successful applicant. In addition, faculty could use these opportunities to identify potential students to mentor and support. This could include helping to connect students with jobs that offer clinical experiences or helping students remain motivated and supported to pursue a 4-year university degree. 25 PA programs also could explore opportunities for CC students to shadow faculty or participate in research projects to enrich potential applicants’ qualifications. 26 Additionally, programs could consider working with partners like the Health Resources and Services Administration’s Area Health Education Centers to create programs to support CC students in more socioeconomically disadvantaged areas. 17,27

Interestingly, not all students with a CC background had decreased odds of matriculating to a PA program. In fact, post-CC students (i.e., those who completed coursework at a CC after completing a 4-year university degree) were more likely to matriculate to a PA program than those with no-CC background. One possible explanation for this finding is the wide variety of prerequisite course requirements for admission to PA programs. Results of the PAEA Prerequisite Curriculum Survey 13 indicated that, in 2018, nearly 100% of PA programs required prerequisite courses, with an average of more than 8 courses required. However, while some courses are required by many programs (e.g., 94% of programs required anatomy), other courses are required only by very few programs (e.g., 3% of programs required physics). More than 70% of respondents to PAEA’s 2018 Matriculating Student Survey 28 reported taking an average of 14.7 additional prerequisite credits before they applied to a PA program. Taking more prerequisite courses may increase the pool of PA programs for which an applicant is eligible, thereby increasing the odds of matriculation. Indeed, our results showed that applicants who applied to more programs were more likely to matriculate than those who applied to fewer programs. Although taking CC courses to satisfy prerequisite requirements may improve the chances of a successful application to a PA program, it also may be financially untenable for low-income applicants or applicants from diverse backgrounds who are more likely to have a lower SES. Ultimately this practice may decrease the diversity of the PA applicant pool. To mitigate this barrier to entry, PA programs may consider decreasing the variety of courses they require and supporting a consensus-driven standardization of prerequisite course requirements. Indeed, 68% of PA programs indicated that they would support the development of universal prerequisites. 13

While our analysis was limited to PA data, our findings are consistent with those of Talamantes and colleagues, 10 who studied medical students, and could apply to other health professions as well. Academic medical centers may want to explore whether admissions policies at other health professions schools, such as nursing, pharmacy, social work, or psychology, are creating unnecessary barriers for CC applicants, thereby limiting opportunities for diversifying the student body. Similarly, academic medicine may want to consider whether strategies such as increasing faculty engagement with CCs could be applied to other health professions as part of a systems-level approach to building institutional capacity for a diverse workforce. 29


First, nearly all PA programs use CASPA. Therefore, while extensive, CASPA data do not cover all PA program admissions and may not reflect applicants outside of the CASPA system. Second, as demographic and SES variables were self-reported and CASPA does not verify them, some of these variables might not be accurate. Third, we were only able to examine matriculation as our outcome variable as PA programs that use CASPA are not required to report other decision statuses, such as acceptance, rejection, and deferral. Finally, PAEA does not currently link CASPA data with matriculants’ academic records as PA students. Thus, we were unable to examine the potential differences in academic performance after matriculation or in graduation rates from PA programs among students in different CC pathways.


CCs are an important pathway to the PA profession. We found that 3 of 4 matriculants in the AY 2016–2017 application cycle had a CC background. Our results suggest that CC applicants are an important contributor to the racial, ethnic, and SES diversity of matriculants to PA programs, yet these applicants are less likely to matriculate than similarly qualified individuals with no-CC background. While the PA profession has recognized the need to increase student diversity, programs may be missing key opportunities to do so, for example, by matriculating similarly qualified applicants who transferred from a CC to a 4-year university at a lower rate than applicants with no-CC background. Critically, our results suggest that some PA programs may have a bias, whether intentional or unintentional, that disadvantages applicants who attended a CC before obtaining a 4-year university degree. Collectively, these findings point to a series of actions that PA programs can take to increase the racial, ethnic, and SES diversity of the profession. For example, programs could carefully assess whether their admissions policies and requirements discriminate against or otherwise create barriers for CC applicants. Likewise, programs might consider identifying new strategies and resources to engage and support CC applicants who are interested in the PA profession. These strategies may help PA programs that are seeking to increase the diversity of their student bodies and, by extension, the workforce, with the ultimate goal of improving the quality of patient care.


The authors wish to acknowledge the Physician Assistant Education Association for providing the deidentified academic year 2016–2017 Central Application Service for Physician Assistants data to the research team.


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