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Do PAs change specialties during their careers?

DEHN, RICHARD W. MPA, PA-C

Journal of the American Academy of PAs: July 2009 - Volume 22 - Issue 7 - p 55–56
Research Corner
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Rick Dehn is a clinical professor in the Department of Family and Community Medicine and program director of the FNP/PA program at the University of California at Davis School of Medicine in Sacramento. He is a member of the JAAPA editorial advisory board.

Physician assistants are unique among health care professionals in that they have the ability to change clinical specialties throughout their careers. Health care workforce researchers have considered this characteristic of PA practice to be valuable because it enables PAs to respond quickly to changes in workforce demand. A critical question, however, is whether PAs actually change specialties during their careers. Three presentations from the 2009 AAMC Physician Workforce Research Conference address this issue.

Arbet S, Lathrop J, Cohn R. Physician assistant specialties of all clinically active PAs: an NCCPA analysis. Presented at: Association of American Medical Colleges (AAMC) 2009 Physician Workforce Research Conference; April 30, 2009; Washington, DC.

National Commission on Certification of Physician Assistants (NCCPA) routinely collects data based on self-reported information collected via a survey presented to all PAs at the time of certification renewal. This longitudinal study examined the actual practice patterns of the population of certified PAs, analyzing the frequency with which PAs change specialties, the specialties among which they tend to move most frequently, and the career stages during which they make those changes. Over the multiple-year survey period, a total of 71,154 females and 57,562 males responded to the survey when they registered for or renewed their certification. Data was presented as frequencies, cross-tabulations, tables, charts, and graphs with simple chi-square tests for finding significant relationships that help describe trends in the data. The data indicate that approximately half of all PAs are newly certified in the past 5 years, recently certifying PAs are choosing specialty areas at a higher rate, and that most PAs will work in two or more specialty areas during their career. While this study is in no way definitive, it does provide valuable insight into the mobility of the PA in the health care system. In a variety of specialties and practice settings, physician assistants bridge critical gaps in the US health care system. This study demonstrates that physician assistant mobility is not just a theoretical possibility but a reality and an opportunity that a majority of PAs exercise over the course of their careers.

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Leinweber W. Physician assistant longitudinal trends in specialty: cohort analysis from the AAPA. Presented at: Association of American Medical Colleges (AAMC) 2009 Physician Workforce Research Conference; April 30, 2009; Washington, DC.

The American Academy of Physician Assistants has tracked a longitudinal cohort of physician assistants for more than two decades. This presentation describes the broad trends of PA specialization and clinical mobility using the prevalence of specialty transitions in a national sample of PAs. For those who changed specialties, reasons for the specialty change are examined. Fifty-seven percent of respondents reported changing specialties at least once, and 49% changed specialties within their first 2 years of practice. Among PAs who changed specialty, the leading reasons for the change were scope of practice, compensation, fringe benefits, work setting, supervising physician, and work status or schedule. When examined by specialty, compensation was a stronger factor for those who left general pediatrics and specialty pediatrics, which are among the lowest-paid specialties for PAs. Scope of practice was an especially important factor for those who left the fields of dermatology, internal medicine subspecialties, and occupational medicine. Reasons for changing specialty did not differ by gender. This project demonstrates that PAs frequently change specialty and suggests factors that may influence these changes.

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Cawley JF. Physician assistant specialization and career mobility. Presented at: Association of American Medical Colleges (AAMC) 2009 Physician Workforce Research Conference; April 30, 2009; Washington, DC.

Over the past 40 years, the physician assistant concept has been shown to be a remarkable workforce policy success in the United States. One factor is that PAs complement physician practices and thus do not threaten the physician's role or authority. The PA concept is spreading globally with programs now in Canada, England, Australia, and the Netherlands. There are presently an estimated 73,500 PAs in active clinical practice. Workforce policy experts believe that PAs are an important asset for service delivery. Anticipated roles involve not only augmentation of primary care services, but also roles in hospital inpatient services and teaching centers. PAs, once seen as important providers of primary care, have increasingly been drawn to positions in specialties and subspecialties. A major trend in the practice patterns of PAs is specialization, now approaching 65% of those in practice. PAs have shown remarkable clinical mobility across medical specialties and settings. The trend of increasing specialization in the PA profession is leading to issues related to the profession's component of clinical flexibility. Increasingly and predictably, specialty groups within the PA profession are seeking advanced training programs and systems of professional recognition and certification. Specialty change is a unique feature among the health professions. Virtually all physicians are postgraduate-trained for a specialty and remain in that specialty their whole career, while nurse practitioners and other advance practice nurses are specialty-trained. In contrast, PAs are capable of changing specialties over the course of their working careers. This presentation draws from an analysis of choices PAs make and where they remain and suggests that skill sets and work experience may be cumulative and contribute to job satisfaction. Gender, age, and other characteristics provide some clues to this mobility. Specialty change is common among PAs.

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DISCUSSION

PAs uniquely possess the ability to change clinical specialties. PA program faculty anecdotally remark that people considering health care careers in the PA profession often cite specialty mobility as a major factor attracting them to the profession. Health care workforce policy experts have noted this unique characteristic and view it as a positive feature because it can contribute to the profession's ability to quickly react to changes in workforce demand. However, until recently no data addressed the question of whether and to what degree specialty mobility actually occurs in the PA profession. The question becomes more pressing in light of recent moves within the profession to consider processes such as specialty testing and certification that may limit specialty mobility, either by requiring additional training before an individual can enter a different specialty or by erecting certification testing barriers. Such processes could decrease the PA profession's ability to react to workforce changes as well as decrease the profession's appeal to future PA applicants. Although specialty mobility is often discussed and frequently touted as one of the profession's unique characteristics, very little is known about it.

Arbet presented survey data collected by the NCCPA during the course of administering the PA certification renewal and recertification examination. Through this process, a large sample (N = 128,716, including repeat responders) was obtained. Within this sample, a question pertaining to the number of specialties practiced during the person's career was answered by 33,135 respondents. Those indicating that they had practiced in only one specialty totaled 37.6%; two specialties, 35.6%; three specialties, 17.5%; and four or more specialties, 9.2%. These data strongly suggest that a majority of PAs exercise specialty mobility during their career, and over a quarter of them change specialties more than once. Conclusions from the NCCPA data are strengthened by the large survey sample size.

Leinweber reported on an AAPA analysis containing 11 years of AAPA census data in which individuals who participated in multiple annual survey cohorts were analyzed. Adjacent cohort dyads were compared to determine if individuals participating in both surveys had indicated a specialty change from one year to the next. Utilizing this method, the rate of specialty movement could be calculated, as well as the characteristics of those making specialty changes. The data showed that as much as half of a given annual cohort of PAs may practice in at least two specialties and 11% will work in three or more distinct specialties over the course of their careers. The first specialty change commonly occurs relatively early in a PA's career. An average of 16% of PAs who participated in each pair of consecutive census surveys reported working in different specialties over the course of the 2-year period.

Cawley presented background information on the PA profession from multiple sources, describing the successful 40-year history of the profession in the United States. Currently, AAPA 2008 census data estimates there are 73,893 PAs in practice, 35% of them in primary care, 64% female, with an average age of 41 years. Of note is a comparison to 1997, when 50% of PAs practiced in primary care. The recent trend toward choice of nonprimary-care specialties by recent graduates mirrors a similar trend in physician graduates. Factors driving this trend are thought to include recent substantial growth in hospital-based job demand, increasing debt load of graduates, and lifestyle choices that favor nonprimary-care specialty practice. Increasing specialization, particularly among new graduates, brings to the forefront the profession's traditional characteristic of clinical flexibility. Historically, this flexibility is based on the premise that PAs work closely with their supervising physicians, making the practice content closely linked to that physician. The assumption has been that PAs and those attracted to the profession find specialty flexibility desirable because it provides opportunities for lateral mobility and professional growth that most health care professions lack. One of the most complex and longest-running debates related to this critical issue of PA mobility centers around the question of the wisdom of developing specialty credentials for PAs. Even applied to that issue, the findings of these studies do not demand a particular course of action but rather illuminate central points of consideration.

With this persuasive evidence demonstrating that specialty mobility is a common characteristic of PA practice, additional research should be undertaken to better understand its impact on the profession and the health care system.

© 2009 American Academy of Physician Assistants.