Chapter Outline
History of Postgraduate Residency Education
General Characteristics of Existing Programs
Residency Program Accreditation
Association of Postgraduate Programs
Residency Graduate Employment Opportunities
Formal clinical training programs are available to provide physician assistants (PAs) with a postgraduate specialty educational experience using the physician residency model of training. These residency programs (sometimes called fellowships) provide graduate PAs with the opportunity to gain supervised clinical experience supplemented with structured didactic work in a specialty area of medicine that builds on the generalist training acquired in the entry-level PA program. Furthermore, the training typically provides an accelerated learning curve in part because of the formalized and structured didactic education component with clinical assignments and formal evaluations intended to support the professional development of the PAs. Most residency programs are located within teaching hospitals or larger clinics and hospitals and are available throughout the United States.
Employment opportunities and clinical roles for PAs have rapidly expanded to include positions in a wide variety of specialty areas. Postgraduate curricula are designed to build on the knowledge and experience acquired in PA school, enabling individuals to assume roles as well-prepared PAs on specialty health care teams more rapidly than those without formal training or prior specialty experience. Many postgraduate programs have pioneered the role of PAs in these specialty areas and offer experienced role models, as well as formalized instruction. Although this training is optional for PAs and only a small percentage of PAs elect to participate in residency programs, they can provide PAs an opportunity to receive formal clinical training, typically in academic medical centers, providing PAs a strong foundation in specialty practice not available as part of entry-level PA education.
History of Postgraduate Residency Education
The first postgraduate PA program began in 1971 at the Montefiore Medical Center in affiliation with the Albert Einstein School of Medicine in New York. Montefiore Medical Center began employing and educating PAs to replace surgical house officers. These PA residents were trained alongside physician surgery house officers. In 1975, Norwalk Hospital and the Department of Surgery at the Yale School of Medicine established a 1-year surgical residency program exclusively structured for PAs, which combined didactic and clinical instruction. By 1980, six postgraduate residency programs were known to exist, and the number has steadily risen from there. At the American Academy of Physician Assistants (AAPA) Annual Meeting in Los Angeles in May 1988, a group of representatives of postgraduate PA residency programs met to formalize a national postgraduate PA program organization—the Association of Postgraduate Physician Assistant Programs (APPAP); bylaws were written and approved by the seven founding member programs.
The exact number of PA residency programs has not been known because of the lack of a consistent means of tracking programs. The most accessible information regarding programs has been the Association of Postgraduate PA Programs (APPAP); however, membership in the APPAP is voluntary, and it is known that many other programs exist. The most recent membership roster of the APPAP dated September 2015 lists 58 programs. The authors estimate that there are nearly 100 postgraduate clinical training programs in total, including APPAP members and nonmembers.
The number of PAs having undergone training in postgraduate residency programs has also been difficult to determine. The most recent published study that surveyed 42 nonmilitary programs found that enrollment was just over 100 PAs, with most programs enrolling 2 or 3 PAs each year. Therefore, it is likely that only 200 to 300 PAs participate in residency training each year. Although comprehensive data regarding the number of current PA residents and graduates is limited, it seems apparent that even with the expansion of PA residency programs, the percentage of PAs training in such programs remains quite small.
Over the years, some of the most important questions asked about PA residency training have included what the potential value of such programs is for participants, what impact these programs have and will have on PA practice, and whether program accreditation will be beneficial or in some way detrimental to the PA profession. Despite these broad questions, relatively little research has been conducted regarding PA residency programs, particularly in recent years.
Program Development
The primary reasons for institutions to develop PA residency programs has included an identified need for additional training for PAs in the specialty, a need to replace physician residents or house officers, and the need to recruit additional PAs to the institution after graduation. Given the work hour restrictions for physician interns and residents and the now well-established role of PAs in academic settings in specialized services, the desire for a formally trained PA workforce will likely remain a major factor for developing programs.
Institutions considering establishing a PA residency program can find valuable resources from the APPAP’s website and at their biannual meetings. The Accreditation Review Commission on Education for the Physician Assistant (ARC-PA) Accreditation Standards for Clinical Postgraduate PA Programs are often used by programs as a blueprint for program development. In addition, institutions’ own physician residency programs and local PA schools may be valuable resources to those considering starting a program. Factors to consider when making decisions about developing new programs include defining the mission and goals of the program; determining what resources are available, including clinical experts such as physicians, PAs, and other professionals in the specialty; identifying didactic materials that are already in place and determining new curriculum needed; and estimating the overall cost for developing and maintaining the program. Several programs have written about their experience in providing residency training to PAs, and reading these may be of value to those considering such an endeavor.
Currently Available Programs
As previously mentioned, the exact number of programs is unknown, and earlier studies relied on membership data from the APPAP. The term “postgraduate” has often applied to both residency programs and academic programs that may or may not provide onsite clinical training. The use of membership data by the APPAP has its limitations because membership does not ensure consistency in the type of education offered, may be inclusive of programs not actively enrolling PAs, and may not include all available programs because membership in APPAP is optional. However, the use of APPAP membership data has provided general information regarding the scope of postgraduate education and a means of contacting programs to participate in survey research.
In 2008, Wiemiller and Somer sought to identify all “postgraduate” PA programs to address the bias in prior studies of omitting programs that were not members of the APPAP. They identified 55 programs; 44 of these programs (76%) were members of the APPAP. Most programs reported enrolling one to five PAs annually. Thirty-eight percent of programs were described as adopting an “academic model,” with 11.4% reporting charging tuition. Because this study sought to include all postgraduate programs, it is likely that it included academic programs offering an advanced degree or academic credit without an emphasis on clinical training. A later study, conducted in 2011, sought to identify only those programs that provided in-house clinical training for PAs at the postgraduate level. Investigators surveyed 43 nonmilitary and 7 military programs meeting this criterion with active PA enrollment in early 2011. Twenty-six programs had enrolled their first PA between in 2008 and 2011, suggesting a significant growth in PA clinical postgraduate program development over this brief 3-year period.
Our understanding of the scope and characteristics of postgraduate programs is limited to data from these recent studies along with the current APPAP membership data with online information provided by programs. Therefore, while reading the following available program information, readers should consider the limitations of these data in understanding PA postgraduate residency programs.
General Characteristics of Existing Programs
Residency programs provide both supervised clinical training as well as formal didactic instruction. These are the hallmarks of residency training, consistent with the model of physician residency programs. Most PA residency programs are civilian programs located in academic health centers. Fewer programs are located in other settings such as community or military hospitals. Most studies have reported on nonmilitary programs, and this chapter focuses primarily on these programs. Less has been published in the literature or online on military PA residency programs.
Residency programs typically provide specialty and subspecialty training, although there have been a few primary care programs such as family or rural medicine programs. The most common specialties represented in current programs include emergency medicine, general surgery and surgical subspecialties, and critical care. However, a variety of medicine subspecialties, such as oncology, psychiatry, and dermatology, are available, although the numbers of these programs remain small.
Most programs are 12 months in duration, and programs shorter than 6 to 12 months are generally not considered residency programs for research purposes or by professional organizations such as the APPAP and ARC-PA. Class sizes vary among programs, from as few as 1 PA resident to 12 or more, with most programs accepting 1 or 2 PAs annually based on published studies. Some newer programs have developed multiple specialty tracks and larger cohorts, enrolling up to 28 PA residents. Institutions may consider their PA residents as trainees, but others may classify them as staff and, in at least one case, they are part of the faculty. It is generally thought that the majority of programs do require residents to be licensed to practice as a PA in the state and have them undergo hospital credentialing and privileging as they do their staff PAs.
Application Process
Given the widely available program information now online, students and other potential candidates are likely able to obtain extensive information online. Member programs of the APPAP are listed at http://www.appap.org , and links to programs’ websites are available on this site. A web search of other programs can help potential candidates identify additional programs. PA specialty organizations such as the American Association of Surgical Physician Assistants may also be a valuable source of information regarding residencies in a specific specialty.
Most students consider additional training while they are in PA schools. Program information is often made available to students during PA school, as part of classes on PA professional issues, during career festivals, and from brochures provide by residency programs to PA schools. However, many PA residents and students report that they do not learn about PA residency programs from their PA schools, and the majority of PA school faculty members have reported that they would not encourage students to consider attending, although the reasons for this have not been investigated.
A residency program selection is often highly competitive, although the ratio of applicants to residency positions has not been published. Although no centralized application service is available that is like the Central Application Service for Physician Assistants (used by most entry-level PA programs), programs require completion of a program application package. The application material required typically includes a program application form, a copy of the diploma from PA school, school transcripts, a curriculum vita, letters of recommendation, and a narrative describing the candidate’s interest in the residency and the specialty area. In addition, nearly all residency programs require personal interviews. Residency directors have reported using many different criteria in making admission decisions for their programs. Commonly used measures include interest in the specialty, interviews, letters of recommendation, level of motivation, academic performance, interpersonal skills, and prior elective rotations or other experience in the specialty.
Historical data indicate that the majority of enrolled residents reported that they had applied to a single residency program. With the expansion of programs, including the presence of multiple programs in some specialties such as emergency medicine and surgery, it is likely that candidates now apply to multiple programs in their desired specialty when they are available.
Admission Requirements
Admission requirements are typically published online by each program. All programs required PA residents to have graduated from an ARC-PA PA program, and most require that they be certified by or eligible for National Commission on Certification of Physician Assistants (NCCPA). Although only half reported requiring state licensure in 1999, it is now thought that most programs have such a requirement. Most programs do not require prior health care experiences before entering a residency program, although some programs may prefer such experience.
Clinical Settings
Most programs are located in academic settings that can provide a wide variety of patient care experiences and a diverse patient care mix. Instructors for residency programs consist of physicians and PAs but may also include advanced practice nurses. Because academic health care institutions employ a wide spectrum of other health care professionals such as clinical pharmacists, dieticians, physical therapists, and others, residents likely have frequent opportunities to learn from these professionals as well.
In recent years, programs have begun collaborating with nurse practitioners (NPs) to offer residencies programs to both PAs and NPs. Although these programs made up a small minority of PA residency programs surveyed in 2011, the authors believe that more programs are now open to both PAs and NPs and anticipate this trend to continue. Current ARC-PA accreditation standards require that PA residency programs be led by a physician or PA; therefore, these interprofessional programs are not currently accredited.
Curriculum
The primary curricular content of PA residency programs is supervising clinical training. Clinical experience is focused around the program specialty, but unlike clinical employment, residencies are organized around a variety of clinical rotations, providing a spectrum of clinical experience for the PA. In addition to required clinical rotations, most programs also offer clinical electives to allow the PA resident opportunities to structure their training around their unique professional interests. Physicians and PA preceptors provide both supervision and instruction during clinical training.
The number of clinical hours required by programs varies from specialty to specialty and from program to program. Data from a study of surgical PAs from 2007 reported residents enrolled in “internship model” programs worked an average of 72 clinical hours per week. Wiemiller and Somer found that 31% of surveyed programs reported requiring in-house call as part of their program, but Polansky et al. found that more than 60% of programs required in-house calls. For accredited programs, work-hour restrictions include limiting work hours (including clinical and academic activities) to a maximum of 80 hours per week averaged over a 4-week period. Other restrictions addressed by the ARC-PA accreditation standards include requiring a minimum of 1 in 7 days free from all educational and clinical responsibilities and 10 hours off from all daily duty periods, including being on call.
In addition to clinical training, residencies provide formal didactic instruction at the beginning of the residency, incorporated throughout the program, or both. In a study published in 2000, residents estimated their total number of hours of didactic education associated with the residency program they attended to be 350 to 413. Subsequent studies have not investigated the specific amount of time devoted to didactic work but have reported on the spectrum of didactic activities that PA residents may be required to participate in. Programs typically include lectures, conferences, required readings, attendance at patient care conferences, grand rounds, online courses, and others. Some programs also require or provide optional opportunities for PAs to give presentations such as at journal clubs, conduct research, and write manuscripts for publication. Many programs also involve their PA residents in teaching through instruction of PA students and other trainees.
Credential Awarded
Earlier studies of PA residency programs described two models of postgraduate training, an “internship model” and an “academic model,” with the later offering academic credit or a degree. Currently, most programs do not award academic credit and instead award a certificate of completion for graduates. This change is likely a result of the change in degrees awarded by PA schools, with a master’s degree now being the standardized academic degree for PA schools.
During the past decade, military programs have offered a clinical doctorate degree. In 2006, the U.S. Army Emergency Medicine PA residency program was expanded from a 12-month program to an 18-month program. The program worked with Baylor University in Waco, Texas, to provide academic credit for their training program that leads to a doctor of science in PA studies (DSc). Since that time, additional military programs have begun offering a DSc with six programs identified in a 2011 study. No civilian residency programs are known to offer doctorate degrees.
Stipends and Fringe Benefits
Data from 2011 indicate that most programs provided an annual stipend between $40,000 and $60,000. At that time, the highest educational stipend reported was between $70,000 and $79,999. Although some programs list salary or trainee compensation information online, comprehensive data on current compensation rates are not available. Benefit packages vary but generally include such items as health insurance, malpractice insurance, paid vacation time, and sick leave.
Residency Program Accreditation
Dating back to 1980, the PA accreditation agencies (the Joint Review Committee, which predated the ARC-PA) and PA educational organizations considered the possibility of establishing an accreditation process for PA residency programs as a means of ensuring educational standards were used by programs. In 1991, the APPAP took the initial step in establishing standards for postgraduate programs by adopting its own set of program “Essentials,” which were intended to identify the desirable elements of a PA residency program. Although APPAP member programs were asked to agree to adhere to the essentials as a condition of membership, compliance with the Essentials was voluntary and was neither formally reviewed nor enforced.
A formal task force with representatives from the ARC-PA and APPAP was established in 1999 to formally consider the issue of accreditation. In 2001, representatives of the AAPA and APAP (former name of the Physician Assistant Education Association) joined the task force, with meetings continuing until 2005. The potential implications on PA education and the profession were explored over time. Although some members of the task force identified accreditation as a means of ensuring core educational standards were met, others expressed concern about the potential for unintended consequences that could result from an accreditation process—specifically the concern that the existence of accredited programs might limit opportunities for PAs not trained in accredited programs to work in specialty practices.
After years of consideration, in March 2006, the ARC-PA voted in favor of offering optional accreditation to PA residency programs. The first version of the accreditation standards was published in 2007. The first two programs were granted accreditation in March 2008, and as of fall 2015, eight programs have been accredited. A list of accredited programs is available on the http://www.arc-pa.org website.
The standards address a wide range of educational administration issues, including ensuring programs have adequate faculty and staff, funding, and patient care experiences. Programs must be full time and be at least 6 months in duration, offering in-residency clinical training and didactic instruction. Programs must adhere to work-hour restrictions as used by the Accreditation Council for Graduate Medical Education. As part of the accreditation review process, the program curriculum must be reviewed by a medical review committee of experts in the discipline to determine if program objectives can be met by the established curriculum, and a site visit is conducted by the ARC-PA. If programs are found to adhere to the accreditation standards, programs would receive accreditation for a maximum of 3 years. An annual report is required each year, and programs must reapply for accreditation after 3 years to maintain their accreditation status. The ARC-PA has emphasized that accreditation is optional.
In July 2014, the ARC-PA announced that the accreditation process of residency programs would be held in abeyance, and a work group would be formed to “discuss alternative methods of recognition of educational quality for Clinical Postgraduate PA Programs.” Based on this decision, the ARC-PA suspended accepting new applications, although accredited programs would retain their accreditation pending the outcome of further study by the commission. The ARC-PA expressed concerns about the labor and resource intensiveness for programs in applying for accreditation as the reason for their decision to suspend the accreditation process for residency programs. As of the fall of 2015, the ARC-PA workgroup has conducted initial meetings, and it is expected that additional information on the status of residency accreditation will become available in 2016.
The issues of program accreditation and oversight have been considered by the AAPA over many years as well. In the 1980s, the AAPA established a policy endorsing a set of standards for PA residency programs. The policy was reaffirmed several times up until 2000. However, in 2005, the AAPA House of Delegates adopted a new policy statement opposing accreditation for postgraduate PA programs. The position statement was revised in 2010, indicating that the “AAPA continues to have concerns about the accreditation of PA postgraduate training programs.” A primary concern raised in the AAPA position paper was the potential of credentialing bodies requiring postgraduate training and that accreditation increases awareness of programs and “with such awareness, the possibility of credentialing bodies preferring or requiring postgraduate training may become more of a reality.” To date, no such requirements have occurred, and at the time of the writing of this chapter, the AAPA policy statement is undergoing review and will be considered at the 2016 AAPA meeting of the House of Delegates.
Association of Postgraduate Programs
The APPAP has remained the primary organization representing PA residency programs. Over the years, the number of member programs has gradually grown from the initial 8 founding members to 58 programs in 20 specialties as of November 2015. The organization states their purpose is to be a resource for PAs and PA students about postgraduate clinical PA education. The APPAP conducts biannual meetings and educational sessions for its members in conjunction with the annual AAPA and Physician Assistant Education Association (PAEA) conferences. The AAPA’s website lists all member programs and provides information about each as well as a link to each program’s website. The AAPA typically provides information during the AAPA conference at a booth in the exhibit hall and with sessions during the regular meeting and the Student Academy of the American Academy of Physician Assistants (SAAAPA) sessions. The Association of Postgraduate Physician Assistant Programs (APPAP) also provides awards to those who conduct research on residency training and to PA residents who conduct research during their training program. Currently, the APPAP responsibilities of membership include the expectation that programs will “adhere to sound educational principles and support other member programs in the pursuit of such principles.” However, accreditation is not required for membership. The APPAP recognizes five classes of membership: Active Program Members, Provisional Program Members, Inactive Program Members, Affiliate Members, and Individual Members.
The APPAP maintains informal liaisons with the AAPA, ARC-PA, and PAEA and works with these organizations on mutual goals to further the PA profession and postgraduate PA education. Additional information regarding current member residency programs, APPAP bylaws, and general information can be viewed at the website http://www.appap.org .
Resident Perceptions of Training
The most common reason PAs decided to pursue residency training appears to be to enhance their competitiveness for jobs in the specialty. Another important reason is the desire of PAs to expand their current level of competency in the specialty, either to obtaining additional clinical knowledge and skills before going into practice or to enhance their ability to change specialty area. Studies of residency graduates have found a high level of satisfaction with their training, and they report being well prepared for their jobs. One very early study found that 20% of former residents believed they were actually overprepared for their job. However, as the scope of practice for PAs has expanded over the past 2 decades and because more recent studies have not investigated this issue, it is not clear if this remains a concern of some graduates. Graduates also report increased confidence and having increased autonomy after residency training. Several reports indicate that residents would recommend their program to other PAs interested in the specialty. The primary disadvantage reported by PA residents is the lower stipends received during training compared with PA salaries in the workplace.
Included in this chapter is a report of interviews with three PAs who attended a residency. The interviews explore the PAs’ perceptions of their residency experience and their reasons for electing to attend a residency program.
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