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Growing pains

Section Editor(s): Bushardt, Reamer L. PharmD, PA-C

Journal of the American Academy of Physician Assistants: May 2014 - Volume 27 - Issue 5 - p 8–10
doi: 10.1097/01.JAA.0000446220.47436.f2

Reamer L. Bushardt is professor and chair of the Department of Physician Assistant Studies at Wake Forest School of Medicine in Winston-Salem, N.C., and editor-in-chief of JAAPA.



Something happened recently that led me to think how the PA profession has historically demonstrated a small-business personality. To celebrate Valentine's Day, I ordered each of my daughters a rose plant paired with a cuddly teddy bear from a large online florist. On the florist's website, a pink satin ribbon tied around the bear's neck matched the small pink rose blossoms. For my wife, I picked out some flowers from a local florist and something sparkly from a nearby jeweler. When the big day arrived, the local florist delivered my wife's gift, despite a rare Winston-Salem snowstorm that made travel difficult for several days. The gifts ordered from the online florist, however, trickled in a week late, and although I'm sure those rose bushes were alive at some point, they were beyond resuscitation when my daughters finally got them.

I gained an increased respect for small businesses from this experience. There are 28 million of them in the United States, mostly home-based, employing half of the American workforce.1 Some of the best qualities of small businesses include hands-on involvement in the creation of products and services, loyal workers who know their customers personally, and engagement in the local community. Even that online mega-florist started as a small business, which made me think about the PA profession and its current growth trajectory.

As the value of PAs is increasingly recognized worldwide, our once-small business is being reshaped by demands for greater production, increased competition among training programs, a seemingly superfluous influx of new and developing programs, market pressures to optimize our practice and improve our efficiency, and political pressures to define our roles with greater clarity and uniformity. Our advocacy groups are scrambling to solidify a PA brand that is relevant today but is not limiting to our future, but as a profession, we have likely grown beyond our ability to easily resolve this emerging identity crisis. Myriad constituent and advocacy groups with differing opinions add diversity and complexity to decision making about our future. We are increasingly trying to behave like a big business, attempting to hold our own among larger health professions and a politically charged healthcare industry. Part of me acknowledges the necessity of this shift toward a more corporate identity, but another part of me worries that we might be losing some of the best attributes of our character in the process. Growth and change seem inevitable, but how can we protect our integrity and preserve our commitment to social justice? These qualities have historically defined our profession, but will they be diminished among so many moving parts?

A recent development in the PA community illustrates this quandary. Lynchburg College in Virginia announced it is developing a new PA program that will offer an option for students who have earned a master's degree to continue for an additional 9 months to earn a doctorate in clinical medicine. In an interview with the Physician Assistant Education Association (PAEA), Lynchburg's new program director suggested that offering this clinical doctorate would increase brand distinction for the college, meet the needs of the institution, and keep pace with other health professions such as pharmacy and advanced practice nursing.2 According to the program director, “...we wanted to bring a noteworthy educational program to this region that would impact the shortage of healthcare providers in this area.” He added, “...the creation of a doctoral PA program would well-suit the needs of the future of healthcare, our students, and the institution.”

Lynchburg College has been incredibly successful in raising the visibility of the institution with this endeavor. I am not convinced, however, that the proposed doctoral pathway will affect healthcare provider shortages or meet future needs of the healthcare community. The PA educational community has demonstrated how effective our current accelerated, competency-based model is at producing capable, competent PA graduates. Furthermore, the additional time and expense undertaken for the clinical doctorate may lead graduates to seek higher salaries, and the healthcare community is already seeking to cut costs. In an article on the growing PA profession, Glicken and Miller described challenges for training programs related to insufficient clinical training sites and the increasingly frequent disruptive effects some emerging programs are creating for established programs by competing for existing sites using preceptor compensation models.3 I find it hard to understand how extending the overall training time and increasing clinical training requirements will address current provider shortages.

During the interview with PAEA, the Lynchburg program director also said, “A challenging issue facing PA education is the lack of doctorally prepared PAs who are able to teach and hold academic rank.” I agree that advancing the preparedness of more of our PA educators through research-intensive doctoral programs is an important goal. However, I do not see how the proposed Lynchburg clinical doctorate will make any meaningful headway. Cawley and Ritsema recently criticized several doctoral training programs targeting PAs that do not integrate in-depth coverage of biostatistics, economic modeling, large dataset analysis, or advanced research methodologies.4 Moving our PA educators ahead will require significant investment in doctoral studies within areas that are synergistic with and complementary to our PA training, such as research, education, administration, economics, business, and basic and translational sciences. My research even suggests that if a program is seeking to improve its student performance on the PANCE, it may be best to focus resources on improving a student-to-faculty ratio, regardless of whether or not the faculty members are doctorally prepared.5

In keeping with its small-business personality, the PA profession has for many years been keen to understand the needs of patients and communities. Standing up for what's right and pioneering nimble pathways to increase access to quality care for our patients have been defining approaches. As pioneers, we have rarely been compelled to follow trends within other health professions. When PA-specific doctorates were opposed in recommendations from the 2009 Clinical Doctorate Summit, it was in part an expression of our character and small business personality. Former PAEA President Justine Strand de Oliviera stated that the recommendations of that summit “uphold the quality of care we give our patients while maintaining the flexibility of the PA profession.”6 I still agree with her.

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1. US Census Bureau. Statistics of U.S. business. http://www.census.gov/econ/susb/. Accessed February 26, 2014.
2. PAEA Networker. Lynchburg College responds to questions about PA doctoral program. http://networker.paeaonline.org/2014/02/05/lynchburg-college-responds-to-questions-about-pa-doctoral-program/. Accessed February 5, 2013.
3. Glicken AD, Miller AA. Physician assistants: from pipeline to practice. Acad Med. 2013;88(12):1883–1889.
4. Cawley JF, Ritsema TS. Where are the PA researchers. JAAPA. 2013;66(5):13,22.
5. Bushardt RL, Booze LE, Hewett ML, et al. Physician assistant program characteristics and faculty credentials on physician assistant national certifying exam pass rates. J Physician Assist Educ. 2012;23(1):19–23.
6. Scott D. PA clinical doctorate summit tackles the degree issue. https://www.aapa.org/uploadedFiles/content/Common/Files/padoctoralarticle.pdf. Accessed March 14, 2014.
© 2014 American Academy of Physician Assistants.