A widely accepted perception, supported by evidence,1–3 holds that the PA profession is an underachiever when it comes to conducting research. This generalization applies to clinical practice, education, historical and sociocultural, and scientific research. Relatively few in the PA world are formally engaged in research pursuits, even in the education sector where research is traditionally expected and rewarded. In one recent survey of PA program faculty, more than half of respondents reported no publications during the past 3 years and half reported no publications over their entire careers!1 Despite more than 40 years of clinical success for the profession, knowledge of the precise content of the care provided by PAs and their practice characteristics is dated, incomplete, and in some cases, nonexistent. Why are we in this unfortunate situation? More importantly, why is research on the profession a critical need?
In the 1970s and 1980s, most research done on the PA profession was sponsored and conducted by non-PAs, usually physicians, health services researchers, health economists, and medical sociologists. These investigations were focused on the “big questions” related to the introduction of PAs: their acceptance by doctors and patients, assurance that PAs could provide safe, high-quality care, and determination of their cost-effectiveness. Once these largely positive results were published, research activity dropped off markedly. The decline led in turn to a reduction in federal support for PA workforce research along with a sense that the big questions had been answered. Our professional organizations might have assumed more responsibility for PA-focused research at that point (in the 1990s), but these organizations had other priorities—such as assuring state practice acts, prescribing authority, and reimbursement—and research productivity suffered. With little money available to support projects, little new research on PA practice characteristics, clinical performance, and health system contributions was produced. Although some scattered efforts were undertaken by a few devoted scholars, research output remained low, particularly when compared to other health care professions of similar age and professional origin.
Sadly, research continues to be a secondary priority within the profession, and we find ourselves playing catch-up when it comes to advancing a PA-focused research agenda. Our contention is that we must change this situation if we are to maintain our position as key players among the health professions.
Many aspects of PA practice remain uncharacterized. Take, for example, PAs in the hospital setting. The 2010 AAPA Census tells us that upward of 38% of PAs are employed in hospitals, but what do we know—other than a few anecdotal reports—about their activities in this setting? The answer is: not very much. We know little about the ways that hospitals employ PAs as house staff or how revenue streams work for inpatient PAs. We have not characterized the content of care delivered by PAs in hospitals, what procedures are performed by PAs in various specialties, or how PAs relate to attending physicians. We know even less about PAs who work in hospitals that sponsor graduate medical education programs. What is the optimal ratio of PAs to resident physicians to maximize patient safety and clinical efficiency in teaching institutions faced with resident work hour limitations? This is an example of a policy-related research question that would inform influential others, such as the leadership of academic medical centers. Ironically, the literature that does exist on PA contribution and utilization in hospitals, teaching services, and ICUs reflects the old patterns; most of the investigators, with a few notable exceptions,4–6 are physicians, not PAs.
High-quality health workforce research requires two key elements: sufficient funding and well-trained investigators. AAPA, PAEA, and NCCPA are all well aware of the limitations of the current literature and have developed several small programs to promote research on the PA profession. For years, these organizations have sponsored or cosponsored grant programs that offered small awards for studies on PA education and practice. Unfortunately, these programs have never been able to provide enough money to fund the large-scale or longitudinal research that would have conclusively answered many pressing research questions. The PA profession has also not been successful at attracting outside foundation support for larger-scale research in the same way, for example, that the Robert Wood Johnson Foundation has supported nursing research. Government-sponsored grants for workforce research often do not include PA practice, although this may change under the Affordable Care Act.
The other limitation to advancing high-quality research on the PA profession is a lack of well-trained PA researchers. Relatively few PAs have PhDs, and those who do often serve as program directors whose time is devoted primarily to administration, not research. Even among PAs who hold the PhD, few have extensive professional experience in grant writing, study design, or study administration. The Doctor of Health Science (DHSc) training programs in which some PAs are enrolled do not offer in-depth training in biostatistics, health economic modeling, analysis of large datasets, or advanced research methodologies. Although the number of PAs who hold an MPH is increasing, only a few are actively engaged in research.
Some of this lack of formal training in research is a consequence of the type of person who chooses to become a PA. Overwhelmingly, PAs choose this career to care for patients. Those considering a career in research may decide to pursue a PhD or MD/PhD. In addition, opportunities for PA educators to pursue research-intensive doctoral degrees are limited. Many institutions with PA programs do not offer doctoral programs in health services research. Some PA programs are so underresourced that they cannot provide the necessary release time to allow faculty to advance their degrees. Other institutions do not see the need or desirability of funding their faculty to obtain the doctorate and do not particularly reward the publication of original research by their faculty members. As a consequence, PA faculty research and scholarly productivity remains anemic.
We offer four potential strategies to improve the situation for PA research.
1. Establish a comprehensive, multiorganizational approach to funding PA research. Each of the national PA organizations can offer only a small amount of funding. If these monies were bundled together, larger studies having greater policy impact would be possible.
2. Mentorship is vital for the development of future PA researchers. PAEA offers a research mentorship program, yet the response has been tepid. In 2011, 16 PAEA members volunteered to mentor others in research, but only six faculty signed up to be mentored! Formal, rich, and long-term mentorship programs to grow PA researchers are needed.
3. Promote incentives for PA faculty to obtain researchoriented doctoral degrees. PA program directors should work to improve and grow the research culture within their institutions to help administrators appreciate the value of PA faculty with advanced research training and the contributions such faculty could make to their university, the PA profession, and to the public discourse.
4. Identify potential future researchers at the student level. PA faculty typically work with bright and curious students who can have a positive impact on the profession. We must encourage such students to consider doctoral training early in their careers and promote pathways for careers in PA-focused health services research.
None of these solutions is easy or quick, but if we do not address the lack of documentation for and promotion of the value of our profession, we risk professional obsolescence.
1. Hegmann TE, Axelson RD. Benchmarking the scholarly productivity of physician assistant educators. J Physician Assist Educ.
2. Hooker RS. Pale sunlight through a dusty lens: physician assistant research. JAAPA.
3. Cawley JF. What we don't know about PAs. Advance for Physician Assistants.
4. Moote M, Krsek C, Kleinpell R, Todd B. Physician assistant and nurse practitioner utilization in academic medical centers. Am J Med Qual.
5. Roy C, Liang CL, Lund M, et al. Implementation of a physician assistant/hospitalist service in an academic medical center: impact on efficiency and patient outcomes. Hosp Med.
6. Kleinpell RM, Ely EW, Grabenkort R. Nurse practitioners and physician assistants in the intensive care unit: an evidence-based review. Crit Care Med.