Physician assistant education: Past, present, and future challenges





Overview of physician assistant education


Physician assistant (PA) education has matured and grown significantly since its humble beginning in 1967 when three ex-Navy corpsman students graduated from Duke University. By the end of 2018, the number of programs had grown to nearly 242, with an estimated enrollment of 23,313 students. , The typical PA program is 27 months long with more than 2000 hours of clinical education and offers a master‘s degree upon graduation. Resident tuition and fees for PA education are much lower in publicly supported schools than private schools, with average costs for students of $47,886 and $87,160, respectively. Typically, students begin their PA education at the graduate level, but some colleges and universities offer 3 + 2, 4 + 2, or other similar options in which the candidate is accepted to the PA track at the freshman level and subsequently completes both a bachelor’s and a master’s degree.


Getting into PA school is quite competitive. There are 23 applications for every matriculant. The typical PA student is white, female, aged 25.4 years, and with an undergraduate grade point average of 3.56. Most PA students would qualify for medical school.


The quality of PA education is ensured by rigorous standards required through accreditation by an independent organization, the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA). The ARC-PA has its roots in the Joint Review Committee on Education for the Physician Assistant (JRC-PA), which was established in 1971 under the auspices of the American Medical Association’s (AMA’s) Committee on Allied Health Education and Accreditation (CAHEA). In 1991 the ARC-PA became an independent body. The most recent (fourth) edition of the Standards for PA Education became effective in September 2010. Currently, the ARC-PA is in the process of developing an updated (fifth) edition, which is expected to be released in 2020 (personal communication, Sharon Luke, June 25, 2019). The Standards establish the minimum requirements for PA education in terms of resources, operations, curriculum, and evaluation and assessment. Although accreditation is voluntary, technically all PA programs must achieve and maintain accreditation because only graduates of accredited PA programs may take the national certifying examination, which is required for licensure in all states. The ARC-PA Commission, which sets policy and makes accreditation decisions, is composed of 25 members representing organized medicine, the PA profession, and the public. In addition to oversight of education at the PA program level, colleges and universities are reviewed and accredited by regional accrediting agencies. Regional accreditation ensures standards are met regarding curriculum, faculty qualifications, and the general operations of the colleges and universities. If an institution loses its accreditation by the regional agency, that would jeopardize eligibility for transfer of credits and participation in the federal student loan programs.


The Physician Assistant Education Association (PAEA) serves as the only advocacy organization for PA education at large. It was founded in 1972 as the Association of Physician Assistant Programs (APAP). Governed by a 12-member board, including one student member, the PAEA provides a wide range of products and services for its member programs. Some of the services PAEA provides include faculty development workshops, testing products (e.g., End of Rotation™ exams), various research reports to inform members and the public, and an annual education forum conference that provides faculty with an opportunity to learn about the latest teaching and evaluation strategies. PAEA also provides oversight for the Centralized Application Service for Physician Assistants (CASPA), which serves as the portal for admission to most PA programs. PAEA’s mission is leadership, innovation, and excellence in PA education.


Brief history of physician assistant education


Overview


Significant advancements and innovations are often attributed to thought leaders who responded to a need and filled the gap. In addition to the actions taken by leaders in the PA education movement, one must also consider what other influential events were occurring around the same time that either provided a stimulus for innovation or the right environment for the innovation to take hold. For each decade starting in the 1960s, a summary of the historical context is reviewed followed by key events that occurred in PA education.


1960s


Historical context


Although many factors may have influenced the development of the PA profession at that time, the 1960s witnessed a time of significant change in the health care arena. Beginning in the 1950s, the U.S. health system began to see growth in the numbers of hospitals as innovations in medicine and treatment shifted the role of hospitals from a caretaking to a curative role. By the 1950s, hospitals employed more people than the steelmaking, rail, and auto industries combined. In July 1965, President Lyndon Johnson signed the Medicare and Medicaid bills into law, which opened the health care doors for many elderly and poor individuals. The original Medicare program provided for hospital (Part A) and outpatient (Part B) insurance that was expected to provide coverage for more than 19 million individuals aged 65 years and older. ,


The need for more health care providers was recognized as physicians began to be attracted to specialties born out of advances in technology and innovations, such as open heart surgery using a heart–lung machine (1953), coronary artery bypass (1967), the beginnings of successful transplant surgeries, and long-term hemodialysis (1960), to name just a few. During the same time, combat medics and corpsmen who served in the Vietnam War were seen as having a strong foundation to fill the gaps in health care.


Physician assistant education events


Although one can find prototypes of the PA profession that were either formally or informally (e.g., apprentice model) prepared, the first formal educational program is generally considered to be the Duke program in North Carolina. Under the leadership of Dr. Eugene Stead, the first class of four PA students began their journey in 1965. Two years later, the first three formally trained PA graduates entered the workforce. Shortly after the first program at Duke launched, Dr. Richard Smith founded the MEDEX model of PA education at the University of Washington in 1969. The MEDEX model (a contract of “Medicine Extension”) combined a short period of classroom study with a longer apprentice-like period with a potential physician employer. Other education models were established by Dr. Hugh Myers at Alderson-Broaddus (the first baccalaureate program) and by Dr. Henry Silver at the University of Colorado (the first graduate-level program). The University of Colorado was first established as a Child Health Associate program with a 3-year curriculum to prepare individuals to work primarily in pediatrics. Early in the PA profession’s history, specialty PA programs were also developed. In 1967 the first entry-level program in surgery was launched at the University of Alabama. Later surgical programs were initiated at Cornell Medical Center in New York and Cuyahoga Community College in Ohio. There were also other entry-level specialty programs in fields such as orthopedics and urology. These subspecialty programs only existed for a short time, and only the three surgery-focused programs survived past 2000.


1970s


Historical context


During the 1970s, the federal government needed to respond to the increasing demand for health care services spurred on by the enactment of Medicare and Medicaid, as well as new health care services available through the advent of technology. In 1970 the National Health Service Corps was established to help address the lack of doctors in rural and inner city areas. In 1971 the Comprehensive Health Manpower Act was passed, creating significant funding for the development of additional PA educational programs. By 1973, the war in Vietnam was coming to a close, which would eventually lead to a decrease in the number of medics and corpsman that would be available to enter the profession. Technological advances in medicine, such as improved antirejection medications for solid organ transplantation, the development of the computed tomography scanner, and the use of arthroscopy meant that medical care was now available for diseases and conditions that previously would have caused morbidity and mortality. Increased demand for medical care meant increased demand for medical care providers, such as PAs.


Physician assistant education events


The 1970s could be characterized as the decade of the professionalization of the PA career. During this time, PA advocacy associations were launched, and the foundations were laid for PA education accreditation and the national certification examination. At the same time, the first growth spurt of educational programs was seen, including the launch of the first postgraduate “residency” program for PAs at Montefiore Hospital in 1971.


Early PA leaders and the AMA’s Council on Medical Education recognized the need for some mechanism to evaluate the quality of educational programs. In 1971 the first accrediting body, the JRC-PA, was established under the auspices of the AMA’s CAHEA. The Essentials of an Accredited Educational Program for the Assistant to the Primary Care Physician standards were adopted and approved by the AMA’s House of Delegates to provide a written document to be used for determining whether or not a program met minimum requirements.


In the early years of the profession, there was also a need to assure state regulators, doctors, and patients that PA graduates had the background knowledge and skills necessary to practice in their chosen field. The Registry of Physicians’ Associates, formed in 1970, issued certificates for approved programs and administered examinations to ensure the competency of informally trained PAs. Later, the Registry was incorporated into the American Academy of Physician Assistants (AAPA) and was dissolved as the National Commission on Certification of Physician Assistants (NCCPA) began to take on the PA certification role in 1975.


In 1972, the first and only organization for representation and advocacy of PA education was formed with 16 charter members. Through funding by the Robert Wood Johnson Foundation, the APAP (later renamed the PAEA) was able to establish a home with the AAPA in Arlington, Virginia. The initial role of the APAP was to facilitate faculty development and the sharing of ideas about curriculum, teaching, and evaluation. The APAP at the time, however, was incorporated into the fabric of the AAPA, and as such the AAPA also took an active role in PA initial and continuing education. One example of their collaboration was in the creation of The Development of Standards to Ensure the Competency of Physician Assistants, which was a five-volume report funded by the federal government that included a role delineation for PAs. The role delineation provided a foundation for mapping PA program curricula.


1980s


Historical context


In 1980, the widely disseminated report of the Graduate Medical Education National Advisory Committee (GMENAC) to the Health and Human Services was issued. The Committee predicted a physician surplus and recommended that medical schools decrease enrollment in the entering class by 10% to 17%. It further recommended that nonphysician health care provider enrollments be capped and called for further research on PAs, nurse practitioners (NPs), and certified nurse-midwives. Nevertheless, GMENAC also included some positive recommendations in their report regarding PAs, such as recommendations to the states to broaden the scope of PA practice and to authorize limited prescriptive authority. In addition, the report contained a recommendation that “Medicare, Medicaid, and other insurance programs should recognize and provide reimbursement for the services of NPs, PAs, and nurse-midwives in those states where they are legally entitled to provide these services” (recommendation 14 of the nonphysician provider panel).


In 1986, through the Omnibus Budget Reconciliation Act, PL 99 to 210, PAs and NPs were approved to receive reimbursement under Medicare. Reimbursement for Medicare services was made to the practice that hired the PA, not the provider. PAs were reimbursed at 85% of the physicians’ rate for hospital and nursing home care and 65% of the physicians’ rate for first assistant in surgery services. PAs providing services in certified rural health clinics were reimbursed at 100%. Reimbursement for PA services provided increased job opportunities for PAs. The improved PA job market stimulated interest in the profession by potential PAs and caused universities to develop new PA programs to meet the increasing demand.


Physician assistant education events


During the 1980s, the growth of PA educational programs plateaued partially in response to the GMENAC report ( Fig. 7.1 ). PA education at the time was still provided predominantly in academic medical centers. In 1985, under the leadership of Dr. Denis Oliver at the University of Iowa, the first national survey of PA education and PA education programs was conducted and published. It has been published consistently ever since. In 2018 the 33rd program survey report was released by the PAEA.




Fig. 7.1


Cumulative total of PA programs since 1965.

(Adapted from: Physician Assistant Education Association, By the Numbers: Program Report 34: Data from the 2018 Program Survey, Washington, DC: PAEA; 2019. doi: 10.17538/PR34.2019.)


1990s


Historical context


Although health maintenance organizations (HMOs) can trace their roots back to as early as 1910 in Tacoma, Washington, there was a rapid growth of HMOs in the 1990s. The rise of HMOs was spurred in part by the need to bring down health care costs as they reached 13.4% of gross domestic product in 1993 and were predicted to reach 20% by the end of the decade. Because the financial model is supposed to favor prevention, many HMOs began to use PAs.


In addition, policy makers became increasingly aware that the dramatic increase in health care costs was not matched by improved patient outcomes. In September 1993, President Bill Clinton announced his intention to lead a major health care reform initiative to address these concerns. Unfortunately, his reform plan did not gain the support of Congress.


Physician assistant education events


Beginning in the mid-1990s, there was another growth spurt in the development of new PA programs. During this decade, an additional 65 programs enrolled their first classes. Throughout the 1990s, there was an increasing realization that the tremendous growth in PA programs was resulting in a high number of PA faculty who were qualified by clinical experience but lacking in teaching skills. The APAP was offering workshops and seminars but formalized these activities in 1998 under the APAP Faculty Development. Initial faculty development workshops were designed primarily to assist faculty with basic skills such as writing better examinations, developing syllabi, and working effectively in the academic environment. There were also extended leadership workshops for individuals new to the program director role. Today, there are 15 different workshops ranging from clinical coordination skills to competency-based education ( paealearning.org/events/ ).


In 1998, U.S. News and World Report ( USNWR ) released its first ranking of graduate-level PA programs. Although there was (and continues to be) much skepticism surrounding the USNWR methodology, inclusion of PA programs in the rankings helped to legitimize PA education within academia.


2000s


Historical context


The 2000s were marked by continued advancements in medicine, many related to discoveries from the Human Genome Project. Personalized medicine became a real possibility for the first time. The terrorism threats after September 11, 2001, and several subsequent cases of anthrax infection resulted in significant federal funding and research into combating threats related to bioterrorism.


This decade was also marked by a national concern for health care quality as evidenced by the release of the seminal report by the Institute of Medicine (IOM) called Crossing the Quality Chasm: A New Health System for the Twenty-first Century, which pointed out the human and financial cost of medical errors. In 2008, Berwick, Nolan, and Whittington proposed a paradigm for improving the nation’s health system. They proposed what is now commonly called the “Triple Aim: improving the experience of care, improving the health of populations, and reducing per capita costs of health care” Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health affairs . 2008;27(3):759-769. doi:10.1377/hlthaff.27.3.759.


Prompted by concerns about medical errors and patient safety from overworked physician residents and influenced by a petition from the American Medical Student Association and others to the U.S. Occupational Safety and Health Administration (OSHA) in 2001, the Accreditation Council on Graduate Medical Education (ACGME) began to look at resident and patient issues related to workload. It was not until 2003 that the ACGME established tighter restrictions on the hours residents could work and be on call. These restrictions were later tightened further in 2011 and contributed in part to the need for more PAs in academic medical centers and teaching hospitals.


Physician assistant education events


One of the seminal events that occurred early in this decade was the endorsement of the master’s degree as the standard entry-level degree to the profession by the PAEA (then the APAP) in October 2000. From 2000 to 2018, the percentage of graduate-level PA programs increased from 49% to 96%. In March 2000, the ARC-PA left the Commission on Accreditation of Allied Health Educational Programs (CAAHEP) to become an independent organization.


The increased interest in PA education by students helped to spawn the CASPA in 2001. This service allows applicants to PA educational programs to file one application and have it disseminated to as many as programs as they choose. Since the launch of CASPA, the number of applicants to PA schools has increased. In the 2005 to 2006 cycle, there were 7933 applicants, and this rose dramatically to 26,978 by the 2018 to 2019 cycle (personal communication, Erika Brooks, May 31, 2019).


The endorsement of the master’s degree as the proper degree for PAs in 2000 did not end the discussion about degrees. The decision of the NP profession to endorse the Doctor of Nurse Practice (DNP) degree as the entry-level degree for NPs spurred further discussion regarding a clinical doctorate for PAs. In March 2009, representatives of the entire PA community and others came together for the Doctoral Summit. The purpose of the summit was “to develop recommendations to the profession on whether the clinical doctorate is appropriate as an entry-level degree, as a postgraduate degree, or not at all.” The outcome of the summit was that the PA profession unified around four recommendations: (1) opposition of the entry-level doctorate, (2) re-endorsement of the master’s degree as the entry-level and terminal degree for the profession, (3) support of postgraduate clinical doctorates, and (4) a recommendation to explore bridge programs to allow PAs advanced standing in medical schools.


2010s


Historical context


One of the most influential events during this decade was the passage of the Affordable Care Act (ACA) in 2010. This act fundamentally changed health care with provisions that increased access to health insurance for millions, allowed young adults to stay on their parents’ insurance plans until the age of 26 years, outlawed denial of health insurance coverage based on preexisting conditions, and required coverage for preventive health measures. In addition, the law directed the federal agency charged with administering Medicare to find and implement measures to decrease the costs of health care. The current administration, with the support of a Republican-controlled Congress, has implemented several policies designed to undermine the ACA.


Physician assistant education events


The 2010 decade will likely be remembered for the third spike in PA program growth, particularly among private, nonprofit colleges and universities not associated with medical schools. During this decade, there were calls for health care to be increasingly delivered by teams of health professionals. Although physicians and PAs have worked as teams since the inception of the profession, there was a recognition that the team needed to be expanded. Two important reports were released in 2011 by the Interprofessional Education Collaborative: Core Competencies for Interprofessional Practice and Team-Based Competencies: Building a Shared Foundation for Education and Clinical Practice. Unfortunately, the PA profession was excluded from the initial members of the collaborative formed in 2009 but was invited to participate in events and became a member in early 2016. During this decade, PA partnerships were strengthened with organized medicine as evidenced by the joint position statement of the PAEA and the Society for the Teachers of Family Medicine. In April 2014, as further evidence of the strengthening of PA and physician partnerships, the PAEA relocated its headquarters to the same building as the Association of American Medical Colleges (AAMC) and the American Dental Education Association (ADEA).


Characteristics of physician assistant education


Physician assistant education is “minds on” and “hands on” from the first day. In a short and intense period of time, PA educators train students to practice in a complex world; they teach students to analyze data, care for patients, work in teams, and demonstrate their own value. Perhaps most critically, they teach students to develop a learner mindset: how to learn, how to reflect, and how to adapt. The PA education model for the past 50+ years has done a laudatory job creating new PA graduates with knowledge of health and disease ready to practice in an ever-changing health care landscape. PA education achieved this by being adaptable, planning for growth in the profession, and watching for changes in clinical practice that could potentially affect the future of health care and the PA profession.


Adaptability is a theme deeply woven into the fabric of the PA profession. One only needs to reflect on the beginning of the PA profession to recognize how quickly change occurs. Early PA graduates could not have foreseen the significant advances that have occurred in both education and clinical practice in the past 50 years. The willingness and ability of PA programs to undergo constant change is unique. The profession, supported by accreditation standards, has always encouraged PA programs in different types of institutions (from public to private and from community colleges to academic medical centers) to evaluate their institutions’ missions and the unique needs of their communities and to regularly implement the changes required to respond to the needs of society.


The differences among PA programs are perhaps most notable at the student application and admission phase. There is a significant variation in admission requirements across all PA programs. Each program has set prerequisites that identify applicants who are most likely to succeed at that particular institution and to progress through the program’s unique curriculum and help the program meet its mission. Multiple studies have pointed out the diversity of prerequisite course requirements and this could have a negative impact on PA programs in the future. ,


PA programs include a number of different admission requirements to help identify ideal applicants for their programs. Historically, the PA profession has been thought of as a “second career,” attracting individuals with years to decades of experience in other fields such as nursing, emergency medicine, and rehabilitation. It remains true today that most matriculants have been employed or have volunteered in a health care field with the mean number of patient contact hours at just under 3000. Nevertheless, as the profession has grown and the number of applicants has increased, we have seen a decrease in both the average age of matriculants and the average health care experience required by programs. , Programs have adapted to attract and accept a younger generation of students and today the average age of the first-year class is 25.


A unique challenge in PA education is the short time during which students move through the curriculum to graduate and become clinicians. The average length of a PA program is just under 27 months, split between didactic and clinical education. This short training period gives programs very little time to deliver a significant amount of education and students very little time to grow into their new professional identities. In addition, unlike doctors, PAs do not typically undergo postgraduate residency training.


PA education provides students with an ongoing stream of appropriately sequenced active-learning experiences. Just over a third of all PA programs integrate clinical training experiences into the didactic year. These introductory clinical experiences put students in the community with a preceptor-mentor to help hone history taking, physical examination, differential diagnosis, presentation, and therapeutic skills before entering their formal clinical rotations. Many programs also provide students with early clinical experiences via service learning activities. Service learning fosters a greater understanding of population health, culturally and socioeconomically appropriate care, and the role that service plays in the practice of medicine.


In today’s curriculum, students are part of the patient-centered team in almost every clinical setting. PA programs, their institutions, and community partners have long shared a common culture of teaching and learning. Providing students with clinical practice experiences would not be possible without strong community partnerships; hospitals, clinics, and preceptors all share in the responsibility with PA programs to provide clinical training to PA students. During the formal clinical education phase, students learn clinical skills, leadership, and professionalism. This intersection between education and practice is an important one, if for no other reason than that many PAs obtain their first PA jobs from a doctor or PA with whom they trained in the clinical year.


Historically, PAs have been educated in a one-on-one clinical training model, meaning each individual clinical student is assigned to an individual clinical preceptor. This model has served the profession well for decades; however, it was designed to train a much more limited population of students at a time when there was not as much competition for training sites. Today, opportunities for students to get to know and assume responsibility for the management of patients is becoming more and more limited. In today’s competitive clinical training environment, there is an emphasis on developing new and innovative clinical training models that better use current resources and continue to provide students with authentic roles in patient care.


Current issues in physician assistant education


Clinical sites


Today there are a number of challenges to effective clinical site and preceptor recruitment and retention, the impact of which can be felt by current PA students. A 2013 survey noted that more than half of all PA program directors report that they are very concerned about having sufficient numbers of clinical training sites and preceptors for students. A changing health care environment that emphasizes increased accountability for patient outcomes combined with decreased reimbursement for clinical services has placed limitations on the number of supervised clinical training placements available to PA programs. Additionally, there has been significant growth in the sheer number of learners in the clinical environment, leading to unintended competition within and among health professions for supervised clinical training placements. , Increasingly, programs are being asked to pay for clinical training—in some cases to the preceptor (clinical instructor), in other cases to the clinical site (health care system, hospital, or clinic) or to both the preceptor and site ( Fig. 7.2 ). The mean cost paid by the program per student per week is currently over $200 and this has contributed to the overall rise in the cost of PA education for students. Additionally, programs are increasingly requiring students to travel further to remote clinical sites. Programs estimate that student’s out-of-pocket housing expenses for remote clinical sites range from $2993 to $7770. Programs may also require students to participate in interprofessional clinical training experiences that accommodate multiple students in a shared rotation. When designed correctly, this can be an incredibly positive experience for the student by helping them build real-life interprofessional practice experience.


Jun 15, 2021 | Posted by in MEDICAL ASSISSTANT | Comments Off on Physician assistant education: Past, present, and future challenges
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