We hear reports about shortages of primary care providers so often and have heard them for so long that we all assume these shortages are critical and likely intractable.1,2 However, those of us in physician assistant (PA) education have watched graduates whom we were certain would choose primary care instead end up in a nonprimary care specialty. Is it possible that there is a shortage of primary care providers, but not a shortage of primary care PAs? In other words, are too few primary care PA jobs available for PAs who may want to practice in primary care? If true, this would have substantial implications for PA education and the many state and federal programs dedicated to graduating PAs to address the primary care healthcare workforce shortage.
In this issue, Morgan and colleagues address PA demand rather than PA supply in “Physician assistant specialty choice: Distribution, salaries, and comparison with physicians.”
One of the primary reasons for the creation of the PA profession was to address the United States' healthcare workforce shortages, which for the most part has been primary care providers. And up until the last decade or so, PAs generally did that—in 1974 an estimated 70% of PAs practiced in primary care.3 Surprisingly, in 1974, 19% of PAs practiced in surgery, a proportion that hasn't changed all that much in the last 4 decades.3,4 In 1995, 57% of newly graduated PAs took their first job in primary care, and over the past 2 decades that proportion has steadily fallen to 28% in 2014.5,6
In 2011, Morgan and colleagues demonstrated that between 1997 and 2006, while the overall number of PAs doubled, the number entering family/general medicine increased 39% and the number entering general medicine increased 61%.7 In contrast, the number entering internal medicine specialties increased 262% and the number entering surgical subspecialties increased 186%. Over the past decade, PA educators have heard many personal stories from our newly graduating PAs that they intended to take a job in primary care, but no such jobs were available. Thus, the anecdotal theory arose that there may not actually be a shortage of PAs in primary care and that instead there actually was a shortage of primary care PA jobs.
In 2015, Morgan and colleagues reported on a research project that for 6 months tracked jobs offered online.8 The analysis sorted the jobs by specialty, and reported that only 18% of the job openings were in a primary care specialty. This is substantially less than the 27% of PAs reported to be practicing in primary care. Although this method of measuring healthcare workforce demand may need validation and some refinement, the data confirmed the anecdotal theories of PA educators—that the demand for primary care PAs may be lower than was generally assumed.
The 2011 Morgan study proposed a hypothesis to explain why the demand for PAs was dominated by specialty positions. The authors noted that medical specialties with the highest percentage of growth in PAs over the previous decade were specialties in which physician salaries were the highest.7
Morgan and colleagues further analyze this hypothesis in their current study, finding that specialties with the greatest difference between physician salary and PA salary demonstrated the highest demand for PAs. The authors speculate that by shifting tasks to PAs, highly paid physicians in specialties may be able to gain more revenue savings than lower-paid physicians in primary care specialties gain from similar task-shifting. If this is true, is this a temporary phenomenon, or is it a feature of how the PA profession has evolved in the medical workforce?
The implications of this finding may be substantial. For years, healthcare professions, PAs included, have been working to increase the number of graduates who enter primary care practice. It is possible that PAs are unique in that the demand for them in primary care specialties may have reached saturation, with the possible exception of medically underserved communities. More research directed at healthcare workforce demand would help direct the profession toward where PAs are most needed.
3. Cawley JF. Physician assistants in the health care workforce. In: Clawson DK, Osterweis M, eds. The Roles of Physician Assistants and Nurse Practitioners in Primary Care
. Washington, DC: Association of Academic Health Centers; 1993.
5. Simon A, Link M, Miko A. Thirteenth annual report on physician assistant educational programs in the United States, 1996-97. Association of Physician Assistant Programs, May 1997.
6. National Commission on Certification of Physician Assistants. 2014 Statistical Profile of Recently Certified Physician Assistants. An Annual Report of the National Commission on Certification of Physician Assistants. www.nccpa.net/Uploads/docs/RecentlyCertifiedReport2014.pdf
. Accessed May 3, 2016.
7. Morgan PA, Hooker RS. Choice of specialties among physician assistants in the United States. Health Aff (Millwood)
8. Morgan P, Himmerick KA, Leach B, Dieter P, Everett C. Scarcity of primary care positions may divert physician assistants into specialty practice. Med Care Res Rev
. [e-pub Feb. 4, 2016]