Racial and ethnic concordance between healthcare professionals and patients is associated with increased access, improved compliance, better interpersonal care, and greater patient satisfaction.1-3 For several years, however, the physician assistant (PA) profession, like many others, has struggled to recruit a workforce racially and ethnically representative of the populations it serves.2,4 In 1999, 12.1% of the US population and 10.6% of PAs were black (compared with 4.9% of physicians).5 Five years later, in 2004, 6.8% of PAs were black and 9.4% were Hispanic.6 As of 2015, 13.3% of the US population was black and 17.6% was Hispanic; however, just 3.7% of practicing PAs were black and 6.5% were Hispanic.7 Among physicians in 2015, 6.4% were black and 6.4% were Hispanic.8
These numbers reflect the fact that, despite active recruitment and the increasingly diverse US population, the percentage of underrepresented minorities entering and graduating from PA programs is decreasing.4,9 PA programs have used various strategies to increase numbers of underrepresented minority students, including holistic admissions processes; however, a report addressing the racial and ethnic diversity of working healthcare professionals between 2004 and 2013 revealed that, among more than 40 professions studied, PAs experienced the highest rate of annual decrease in blacks (0.495%).4,10 In 2014, whites had the highest applicant-to-matriculant ratio for PA programs, and just 2.92% of PA matriculants were black, and 7.1% were Hispanic.11
Although decreasing diversity is not unique to the PA profession, it is especially concerning for a profession whose history reflects a commitment to caring for underserved populations and educating clinicians from diverse backgrounds. In addition to the improved outcomes associated with racial and ethnic concordance between healthcare providers and patients, underrepresented minorities are more likely to serve underrepresented minority populations.1 Therefore, in order to fulfill its historical mission to increase access and improve healthcare for populations in need, the PA profession must determine how to effectively recruit and educate more students from diverse backgrounds.
Until the 1990s, a higher percentage of underrepresented minorities enrolled in PA programs compared with other healthcare professions programs such as medical school.12 Since 2000, PA education has experienced substantive changes, including the move to an entry-level master's degree, a significant increase in the proportion of programs housed in private institutions, and substantial growth in the number of programs. As of the fall of 2016, 218 programs were accredited; of those, nearly a quarter (24.3%) were new programs with initial provisional accreditation. In addition, 52 new programs are scheduled to be evaluated for provisional accreditation between now and March 2020.13
Professional program characteristics, such as location and percentage of underrepresented minority faculty, may influence student diversity. In their 2015 analysis of factors that influence students' choice of PA programs, Klingler and Van Rhee found that program location was a primary consideration.14 Andersen and colleagues found that, in addition to the population demographics of a program's location, percentage of underrepresented minority faculty correlated with underrepresented minority student recruitment to dental schools.15 Academic preparedness of students also may play a role. Educational institutions report that students from disadvantaged backgrounds often need additional training in order to meet prerequisites for healthcare professions programs.2 Notably, healthcare occupations requiring several years of education tend to be the least diverse.4 Thus, the level of degree a PA program offers may also influence the number of underrepresented minorities who attend. With regard to the PA profession in particular, in the midst of significant expansion and change, understanding the potential effects that program characteristics have on student characteristics may be necessary if the profession is to increase diversity among its ranks. The primary aims of this study were to determine how underrepresented minorities' participation in PA programs has changed over time and to identify PA program characteristics that may be associated with higher or lower percentages of underrepresented minority students. The identification of potential influences on diversity among students may help the PA and other healthcare professions recruit and retain a greater proportion of underrepresented minority healthcare professionals.
Sample and instrument
Raw, deidentified data from the Physician Assistant Education Association (PAEA) program surveys for the years 2002-2003 and 2012-2013 were analyzed. The 2 years examined were chosen in order to identify any changes over a 10-year period. PAEA distributes the survey annually to all accredited PA programs in the United States; responses are generally provided by program directors or their designees. The instrument consists of multiple program-related questions related to general information (such as location and program length), finances (such as budget and tuition), personnel (such as demographic characteristics and faculty workload), and students (such as demographic characteristics and graduation rates). PAEA has modified the questions over time; a link to the report associated with each of the years included in this analysis can be found at http://paeaonline.org/research/program-report. Overall response rates for the survey are generally high. Initial response rates for the years analyzed were 84.1% (111/132) in 2002-2003 and 100% (171/171) in 2012-2013.
Descriptive statistics were used to determine the race and ethnicity distribution of first-year students in programs with different characteristics. Bivariate correlation coefficients identified relationships between these program characteristics and percentage of Hispanic and black first-year students. Finally, multiple linear regression was performed to determine the relative influence of each program characteristic on variations in the percentages of Hispanic and black students, while accounting for the influence of all characteristics included.15
The program characteristics identified as potential explanatory (predictor) variables (such as funding status [public, private nonprofit, private for-profit], geographic region, highest credential awarded, and, for 2012-2013, percentage of Hispanic and black PA program employees) were chosen due to their availability within the data and as variables likely to effect the percentage of underrepresented minority students in a professional program. Because tuition costs of public programs are generally lower than those at private programs, the funding status variable may be viewed as a proxy for program cost. Hiring and funding standards also frequently differ for public and private institutions. In order to describe the potential influence that the increase in the proportion of privately funded programs has had on percentage of underrepresented minority students, public funding was selected as the reference category for funding status.
Region was included because students frequently attend programs close to where they live.14,15 Geographic locations consisted of the US Census Bureau regions: Northeast, Midwest, South, and West. Further delineation of region was not possible due to the potential that more specific location information would inadvertently reveal the identity of individual programs to the researchers. Northeast is the most prevalent region and was therefore chosen as the reference category for this variable.
Level of highest credential was designated as master's degree or no master's degree (such as certificate, associate's degree, and bachelor's degree). To describe the potential influence that transition to the master's degree has had on percentage of underrepresented minority students, no master's degree was used as the reference category. Due to the construct of the PAEA program survey in 2002-2003, extraction of the percentages of Hispanic and black faculty and staff was not feasible; therefore, this potential explanatory variable was only included in the 2012-2013 data analyses. Of note, the percentages of Hispanic and black faculty and staff were reported as single variables in the PAEA survey: percentage of Hispanic employees (faculty and staff combined) and percentage of black employees (faculty and staff combined).
We were interested in underrepresented minority students other than Hispanics and blacks; they include Native Americans, Alaska Natives, Native Hawaiians, and Asians other than those who are Chinese, Filipino, Japanese, Korean, Asian Indian, or Thai.16 However, underrepresented Asians could not be accurately differentiated from non-underrepresented minority Asians in the data, and the numbers of other underrepresented minorities were too low for meaningful analysis. Therefore, the outcome variables were defined as percentage of Hispanic students and percentage of black students.15
The 2002-2003 survey treated race and ethnicity as a single characteristic. Consistent with the 2010 change in federal reporting requirements that identify ethnicity (Hispanic/non-Hispanic) as separate from race, the 2012-2013 PAEA program survey differentiated the two. In response to the 2012-2013 survey, some programs provided responses related to ethnicity while failing to provide information about race and vice versa; therefore, we completed two separate analyses on the 2012-2013 data. Percentage of Hispanic students served as the outcome variable for evaluation of all of the programs that provided sufficient data on student ethnicity; percentage of black students served as the outcome variable for evaluation of all programs that provided sufficient information on race. In all data sets, outcome variable percentages were skewed; therefore, base-10 logarithm (log10) transformations were performed before the analyses, resulting in normal or nearly normal distributions in all cases.
Insufficient or unclear data resulted in the elimination of some of the responding PA programs from each year's analysis. Accounting for excluded programs as well as those that did not respond to the survey, final response rates were 73% (96/132) for 2002-2003, 77.2% (132/171) for the 2012-2013 examination of Hispanic students, and 80.1% (137/171) for the 2012-2013 examination of black students. Some variation existed in the characteristics of the relatively small number of programs that were excluded from the final analyses compared with those that were included (Table 1).
Data available for 34 programs excluded from the 2002-2003 analysis revealed that excluded programs conferred a lower percentage of master's degrees than included programs (44.1% versus 58.3%). In addition, data for 37 programs excluded from the 2012-2013 analysis involving ethnicity showed that a higher percentage of excluded programs were private for-profit (13.5% versus 9.1%) and a higher percentage conferred master's degrees (94.6% versus 91.6%). Similarly, data for 32 programs excluded from the 2012-2013 analysis involving percentage of black students also showed that a higher percentage of excluded programs were private for-profit (25% versus 7.3%) and a higher percentage awarded master's degrees (96.9% versus 92%). Although most programs were included in the analyses, the differences between the characteristics of included and excluded programs may have skewed study results.
Due to the 2010 change to reporting race and ethnicity (Hispanic/non-Hispanic) separately, comparisons from before and after 2010 are inexact. The data available, however, showed that between 2002-2003 and 2012-2013, the percentage of white first-year students in PA programs increased from 77.2% to 79.6%. The percentage of underrepresented minorities decreased; in 2002-2003, 6.2% of first-year students were black and in 2012-2013, 4.4% were (Figure 1). Among privately funded programs (nonprofit and for-profit), which now account for 65.5% of PA student enrollment, the percentage of white first-year students increased from 76.5% in 2002-2003 to 81.8% in 2012-2013.9 In comparison, in publicly funded programs, the percentage decreased slightly, from 78.5% to 78% (Figure 2). Analysis of diversity by region revealed that, consistent with the demographics of regional populations, PA programs in the West had the highest percentage of Hispanic students (12.2% in 2012-2013) and programs in the South had the highest percentage of black students (6.1% in 2012-2013). With regard to degree, in 2012-2013, the percentage of white students attending master's degree programs was 82.7%; the percentage of white students attending non-master's degree programs was 46% (Figure 3), compared with 2002-2003 when the percentage of white students attending master's degree programs was 80.8% and the percentage attending non-master's degree programs was 71.5% (Figure 4). Overall in 2012-2013, non-master's degree-granting programs accounted for just 6.6% of all PA students but for 28.4% of black students and 23.8% of Hispanic students.
In general, bivariate correlation analyses revealed negligible or very modest relationships between the variables tested and ethnicity or race of students. Consistent with population demographics, West region had a modest positive correlation and Midwest region a modest negative correlation with percentage of Hispanic/Latino students in both years tested (Table 2). In 2012-2013, the percentage of Hispanic program employees had a moderate positive correlation with percentage of Hispanic students (r = 0.393, P < .01); master's degree had a weak negative correlation (r = -0.281, P < .01). Master's degree had a moderate negative correlation with the percentage of black students in both years, and the 2012-2013 analysis showed that the percentage of black employees had a moderate positive correlation with black students (0.367, P < .01) (Table 2).
Multiple linear regression performed on the 2002-2003 data set using funding status (public, private nonprofit, private for-profit), region, and highest credential (master's degree compared with non-master's degree) as explanatory variables and percentages of underrepresented minority students as outcome variables indicated that the three predictor variables explained 24.6% of the variance in percentage of Hispanic students (log10) (R2 = 0.246, F [6, 89] = 4.831, P < .001) and 21.2% of the variance in percentage of black students (log10) (R2 = 0.212, F [6, 89] = 3.980, P < .001). When accounting for the effects of all of the selected program characteristics, Midwest region was negatively associated (beta = -0.237, P = .034) and West region was positively associated (beta = 0.367, P = .001) with percentage of Hispanic students; only master's degree was statistically significantly associated with percentage of black students (negative association: beta = -0.384, P < .001) (Table 3).
Multiple linear regression performed on the 2012-2013 data sets included an additional explanatory variable (percentage of Hispanic employees or percentage of black employees) and indicated that the four predictor variables explained 32.9% of the variance in percentage of Hispanic students (log10) (R2 = 0.329, F [7, 124] = 8.676, P < .001) and 24.5% of the variance in percentage of black students (log10) (R2 = 0.245, F [7, 129] = 5.965, P < .001). When accounting for the effects of all of the selected program characteristics, West region (beta = 0.31, P < .001) and percentage of Hispanic employees (beta = 0.308, P < .001) were positively associated with percentage of Hispanic students, whereas master's degree had a negligible association (beta = -0.144, P = .072). Percentage of black employees was positively associated with percentage of black students (beta = 0.265, P = .002); West region (beta = -0.194, P = .029) and master's degree (beta = -0.262, P = .003) had weak negative associations (Table 4).
Diversity in the healthcare professions
In 2004, the Institute of Medicine (IOM) and the Sullivan Commission on Diversity in the Healthcare Workforce, a group of leaders in healthcare, business, higher education, and law, called for increasing minority representation in the healthcare professions to reduce healthcare disparities and improve the nation's healthcare.1,17 In its report, Missing Persons: Minorities in the Health Professions, the Sullivan Commission identified three overarching issues to address:
- culture change in the healthcare professions
- new and nontraditional paths to healthcare professions education
- commitment at the highest levels of institutional and organizational leadership.17
Through various funding programs, government agencies have provided support to increase the number of underrepresented minorities in healthcare professions. Between 2008 and 2013, the Health Resources and Services Administration (HRSA) Scholarships for Disadvantaged Students program awarded about 1,649 scholarships to PA students. From 2008 to 2013, the percentage of the program's recipients who were underrepresented minorities ranged from 51% to 60%.2 Additionally, HRSA Title VII PA training in primary care grants give priority to proposals designed to increase the proportion of underrepresented minorities enrolled in PA programs.18
Underrepresented minorities are well-represented in healthcare professions that require relatively lower levels of education and training, including professions such as medical assistant, from which the PA profession draws some of its applicants. In fact, racial and ethnic diversity has increased in many of these healthcare professions (such as licensed practical nurse, medical assistant, and home health aide) and exceeds that of the US population in general.4 In past years, the PA profession drew more heavily from other healthcare professions, as opposed to drawing from large numbers of applicants who have college degrees but relatively little healthcare experience. In 2002-2003, students entering PA programs had an average of 37.7 months of healthcare experience; in 2012-2013, the average was 26.1 months (19.3 months of direct patient care and 6.8 months of other healthcare experience, such as laboratory technician or front office worker).19,20 The requirement for a bachelor's degree to enter most PA programs likely contributed to this shift.
Other healthcare professions
Like the PA profession, occupational therapy (OT) and physical therapy have been transitioning to higher degrees over the last several years. As previously discussed, the 2010 change to reporting race and ethnicity (Hispanic/non-Hispanic) separately makes it difficult to compare, with complete accuracy, numbers reported before and after 2010. Nonetheless, the available data show that during OT's transition from bachelor to master's level (between 2003 and 2013), the percentage of white students increased from 79% (white) to 82% (white, non-Hispanic) while the percentage of blacks decreased from 8% to 4%.21 The American Occupational Therapy Association concludes that the transition to the master's degree did not significantly affect diversity in the profession; however, others may view a 50% decrease in the percentage of blacks as significant, particularly considering the lack of diversity in healthcare professions requiring higher levels of education.21 Between 2004 and 2013, the percentage of PT programs granting doctoral degrees increased from about half to nearly 100%. During this period, the percentage of white students increased from 78.5% to 79.4%; the percentage of Hispanic students remained relatively constant (7.4% to 8%) and the percentage of black students decreased from 9.2% to 4.9%.22 Healthcare professions that have not changed degrees also have lost ground in underrepresented minority representation.4 However, considering the similarity among professions that have changed degrees, exploring the potential effect of entry-level degree on underrepresented minority participation in professions other than PA may be worthwhile.
In 1998, the Association of Physician Assistant Programs (APAP, now the PAEA) commissioned a task force to examine the issue of entry-level degree for the PA profession. In its final report published in 2000, the task force recommended that PA programs grant graduate degrees. However, task force members recognized that, “...the most serious potential consequence for the profession may be disenfranchisement of its members who lack the degree set as the standard, and who lack the resources or interest to seek a more advanced degree.”6 Consequently, they acknowledged that some institution's missions may be better served by non-master's degree programs and pledged to work with the American Academy of PAs (AAPA) to create initiatives to increase the representation of underrepresented minorities in the PA profession.6 In 2010, PAEA reaffirmed its commitment to support community colleges and requested an investigation of the potential effect that community college PA programs have on workforce diversity and access to healthcare.23 At this point, it appears that the loss of community college PA programs will result in a loss of diversity in the profession, although the ultimate outcome of the final transition to graduate level remains to be seen.
Additionally, over the last decade the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA) has emphasized the need for PA program graduates to achieve high Physician Assistant National Certification Examination (PANCE) first-time passing scores, thus encouraging programs to work toward high pass rates. The resulting pressure on programs to graduate students who obtain high PANCE scores may encourage program admissions committees to overemphasize applicant performance on standardized examinations such as the Graduate Record Examination (GRE), compared with other criteria, potentially leading to fewer underrepresented minority applicants being selected for admission.24,25
A variety of factors likely contribute to the lack of diversity in some healthcare professions; characteristics of educational programs may be among them. Results of this study reveal that privately funded PA programs had slightly lower percentages of underrepresented minority students than publicly funded programs, although funding status was not shown to significantly influence a program's percentage of Hispanic or black students. Nevertheless, due to the significant increase in the proportion of privately funded PA programs in recent years, further study of the potential effect of funding status and cost of program attendance on underrepresented minority entrants into the PA profession is warranted.
The modest but statistically significant association found between degree and PA program student diversity also is notable. As of 2013, undergraduate-level PA programs had greater success matriculating underrepresented minority students than master's degree programs. By 2021, however, PA programs will no longer confer undergraduate-level qualifications. The transition of PA education to graduate level is consistent with the PA profession's endorsement of the PA master's degree (as opposed to a clinical doctorate) that resulted from a 2009 summit supported by PAEA and the AAPA.26 Yet, even as some PA programs grapple with the challenge of converting to master's level, calls for PA education to move to doctoral level persist.
Despite the efforts of the federal government and concerns amplified by the IOM, the Sullivan Commission, and PA professional organizations, the enrollment of underrepresented minority PA students has experienced a decade-long decline. This has resulted in decreasing diversity in the PA profession, as the graduating cohorts over the last decade have been the largest of the profession's history. If this trend is not quickly addressed, the PA profession's ability to provide culturally competent care to America's increasingly diverse population may be compromised.
Expansion of federal programs that already exist is one potential solution. The HRSA Scholarships for Disadvantaged Students program gives financial support to underrepresented minority students in the healthcare professions, and the HRSA Title VII PA training in primary care grants support programs that admit higher proportions of underrepresented minorities. An additional approach would be expansion of support for “pipeline” programs, such as HRSA's Health Career Opportunity Programs that are designed to attract underrepresented minorities to healthcare professions and provide support to increase their preparedness to apply to PA programs. Increasing the number of programs that accept students at the undergraduate level and, after prerequisite and baccalaureate degree completion, automatically matriculate them into the graduate PA program also may have an effect. Finally, ARC-PA may be able to contribute by de-emphasizing PA program first-time PANCE pass rates in favor of emphasizing overall pass rates and adding an accreditation standard that encourages programs to increase diversity.
Ultimately, strategies must go beyond admitting a greater proportion of underrepresented minority students to PA programs. According to the 2016 PAEA By the Numbers Program Report, in 2015, 94.7% of white PA students graduated with their original cohorts, compared with 90.9% of Hispanic, 90.9% of Asian, 86.4% of Native American or Alaska Native, 80.3% of black, and 76.9% of Native Hawaiian or Pacific Islander PA students.9 Additional research on the factors associated with underrepresented minority attrition is needed to inform efforts to educate and graduate higher proportions of these students.
The variables included in this analysis are those shown to be associated with underrepresented minority student participation in healthcare professions; however, the small number of variables limited the ability to identify other factors that may contribute to student diversity within PA programs. In addition, although most programs were included in the study, insufficient data precluded examination of all programs. Finally, the PAEA program survey was not designed for inferential statistics; therefore, data transformations were necessary for analysis. Despite these limitations, study results highlight the need to learn more about factors that influence underrepresented minority participation in PA programs.
State and local population demographics in the four US census regions vary. Therefore, although the multiple linear regression analyses accounted for US census region, the relationship found between percentages of Hispanic employees and students and between percentages of black employees and students may be partly attributable to local demographics of PA program locations. Still, the positive association is comparable to research showing that underrepresented minority representation among dental school faculty positively influences underrepresented minority student recruitment and suggests that increases in the proportion of underrepresented minority PA program employees may similarly influence underrepresented minority PA student enrollment.15
Degree is not the only issue associated with diversity in the healthcare professions; however, this study's results support the assertion that it is a contributing factor. Therefore, support for existing diverse PA programs, including those that will need to transition to graduate level, will be important for maintaining diversity in the profession as a whole. Evidence for the effectiveness of strategies to increase diversity in healthcare professions education is limited. However, the greatest potential likely stems from comprehensive approaches involving multiple interventions, for example, restructuring admissions policies, providing financial and social support, and developing innovative training opportunities, which will require clinicians to actively engage in educating the profession's next generation.4 Recruiting underrepresented minority PAs to serve as educators also may have a positive effect.
More than 12 years have passed since the Sullivan Commission called for healthcare professions to examine their culture, paths to their profession, and leadership in order to increase the proportion of minority healthcare professionals.17 Although the PA profession, like others, has failed to adequately respond, the PA community remains committed to diversity.27 Still, reversing the decline in underrepresented minority representation among PAs will likely require a concerted effort. In order to contribute to a more diverse, and therefore more effective, healthcare workforce the PA profession will need to acknowledge the issue, continue to study it, and take action.
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