Postgraduate clinical training programs for physician assistants





Introduction


Employment opportunities and clinical roles for physician assistants (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 expert clinical 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 with an opportunity to receive formal clinical training, typically in academic medical centers, giving PAs a strong foundation in specialty practice not available as part of entry-level PA education.


The education model of physician assistant residencies


In the early days of the PA profession, a model of providing postgraduate specialty clinical training, similar to the residency model used for physician graduate medical education, was established for PAs. In 1971 the first postgraduate program to train PAs in surgical practice was established at the Montefiore Medical Center in affiliation with the Albert Einstein School of Medicine in New York. These PA residents were trained alongside physician surgical residents to expand the number of house officers. In 1975 the Norwalk Hospital and the Yale School of Medicine established a second PA surgical residency program, this one designed for PAs only. By the 1980s, several other PA residency programs were developed, providing training opportunities in a variety of specialties, including surgery, emergency medicine, and pediatrics. As time passed, other residencies were developed until programs were established in most surgical and medical specialties and in nearly every state in the United States. Although the number of residency programs have expanded over the years, the total number of PAs participating in such programs has remained low and is no more than a small percentage.


Although PA residency programs were modeled after physician residency programs, some important differences exist. First, postgraduate training is not required for PA practice, licensure, or certification. Therefore PA enrollment in residency programs has been completely optional and guided by the unique professional interests and goals of individual PAs. Next, until recent years, only a few residency programs have existed in any particular discipline and consequently a standard curriculum for each discipline has not been established. Because PA residency programs are shorter than physician residencies, PA programs cannot simply adopt a physician residency curriculum in its entirety. Instead, each PA residency program has needed to identify its own goals and objectives to guide the training of PAs to develop the clinical competencies identified by the program as relevant to PA practice within the identified specialty. Another unique difference from physician programs has been the lack of an established accreditation process (discussed in further detail later) guiding the development, implementation, and evaluation of such programs. Furthermore, although most PA residency programs have provided only a certificate of completion, as do physician residency programs, some programs have awarded academic credit and some graduates have earned academic degrees. , Finally, given the similar scope of practice of nurse practitioners (NPs) and PAs in many practice settings, an increasing number of PA residency programs also enroll NPs and therefore these programs represent a unique model of interprofessional education. , Given these important differences from physician residencies, these programs have faced unique opportunities and challenges during the nearly 50 years of their existence.


Association of postgraduate physician assistant programs


With the growth in the number of PA residency programs in the 1980s came the desire for program leaders to network with others involved in PA postgraduate education. The American Academy of Physician Assistants’ (AAPA’s) annual conferences provided this opportunity. During the AAPA Annual Meeting in May 1988, and after several years of informal meetings, a group of representatives from seven postgraduate PA residency programs established a new organization—the Association of Postgraduate Physician Assistant Programs (APPAP). Since that time, the APPAP has been the primary organization representing PA residency programs. Its primary purpose is to support established and developing PA residency programs, and it is also a source of information for PAs, PA students, and entry-level PA programs regarding postgraduate clinical education. In addition to active and provisional program membership, the APPAP allows for the individual membership of PAs and students. Individual members may participate in APPAP business meetings and serve on committees. Although program membership in APPAP is voluntary, APPAP membership data has provided the most comprehensive information to date regarding existing programs. The APPAP holds membership meetings biannually, including during the AAPA annual conference when they typically also have information sessions for those wishing to learn more about PA residency training opportunities. In addition, the APPAP has recently begun collaborating with the Association of Postgraduate Advanced Practice Registered Nurse (APRN) Programs to provide workshops in the development of advanced practice provider (APP) postgraduate training programs.


Program accreditation


Program accreditation has not been widely adopted for PA residency programs as it is for other types of educational programs, including entry-level PA programs and physician residencies. Accreditation is a process of ensuring educational institutions or programs meet established quality standards as determined by an external body and is intended to foster program improvement. Accreditation is intended to be voluntary and because residencies are not required for PA licensure, certification, or practice, there have been no significant drivers for accreditation, such as those for physician residency programs. Although interest in the accreditation of PA residency programs dates back decades, it was not until in 2006, when the Accreditation Review Commission on the Education for the Physician Assistant (ARC-PA) voted in favor of offering accreditation to qualified PA residency programs. The ARC-PA accreditation standards for PA postgraduate clinical training addressed a wide range of educational administration issues, including ensuring programs have adequate faculty and staff, funding, and patient care experiences. Programs were required to be full-time and to last at least 6 months in duration, offering in-residency clinical training and didactic instruction. The curriculum had to be reviewed by a medical review committee of experts in the discipline to determine whether program objectives could be met by the established curriculum. The first two PA residency programs were granted accreditation in March 2008, and as of 2014, only eight programs had been accredited. In August 2014, however, 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.” After some delays, in 2019 the ARC-PA voted to approve a revised accreditation process and set accreditation standards. At the time of this writing, it is expected that programs will be able to apply for accreditation by 2020. Because accreditation will remain optional and given the time typically required to apply for and be granted accreditation, it is unlikely that accreditation of PA residencies will be widespread in the near future.


Currently available programs


The exact number of residency programs is unknown because of the lack of a required accreditation that would ensure all programs were identified. Nevertheless, membership data from the APPAP have been valuable sources of information regarding available programs and trends in program growth. The use of APPAP membership data has important limitations because of membership being optional. Further limitations exist in the use of the APPAP membership roster as a source on information about residency programs because membership does not ensure consistency in the type of education offered and may be inclusive of programs not actively enrolling PAs. Nevertheless, the use of APPAP membership data has provided important information regarding the scope of postgraduate education and has been a means of contacting programs to request participation in survey research.


The most recent membership roster of the APPAP includes approximately 100 member programs with about half in surgical specialties and emergency medicine ( Fig. 38.1 ). It should be noted that PA residency programs in the military and in Veterans Affairs are not members of the APPAP and many other residency programs are known to exist. The authors estimate that only approximately half of all residencies are member programs of the APPAP. Therefore there are likely 200 or more programs in existence across the United States. Although there has been a rapid growth in the number of residency programs, particularly in recent years, programs typically enroll small numbers of residents, and given the concurrent growth of entry-level programs, it is likely that the percentage of PAs participating in residency programs has not substantially increased in recent years.




Fig. 38.1


Trends in postgraduate program expansion. Known programs.


Historically, studies of PA residency training have primarily used the APPAP membership roster to survey programs and residents. More recently, investigators have attempted to identify non-APPAP members as well to provide more comprehensive data on programs. Nevertheless, with the lack of a comprehensive source for all programs, limitations to reported data exist. The authors’ understanding of the scope and characteristics of postgraduate programs is informed by data available from published studies along with online information, most notably from the APPAP website, as well as anecdotal information obtained from professional involvement in PA residency programs dating back to the 1990s. Therefore, while reading the following available program information, readers should consider the limitations of available data in understanding the full landscape of PA postgraduate residency programs.


General characteristics of existing programs


The educational model adopted by residency programs consists of both supervised clinical training and formal didactic instruction. These educational activities are the hallmark of residency training, consistent with the model of physician residency programs. Most PA residency programs are located in academic health centers. , Other programs are located in settings such as community or military hospitals. Most studies have reported on nonmilitary programs, and this chapter focuses primarily on these programs. Much less has been published in the literature or online about 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. Nevertheless, a variety of medicine subspecialties, such as oncology, psychiatry, and dermatology, are available, although the numbers of these programs remain small.


Most programs last approximately 1 year in duration, and programs shorter than 6 months are generally not considered residency programs for research purposes or by professional organizations such as the APPAP and ARC-PA. Cohort sizes vary among programs, from as few as one PA resident to 12 or more, with most programs accepting one or two PAs annually based on published studies. , Some newer programs have developed multiple specialty tracks with larger cohorts, enrolling up to 28 PA residents. Institutions may classify their PA residents as trainees, whereas others may classify them as staff and, in at least one program, 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 make them undergo hospital credentialing and privileging as they do their staff PAs.


A recent trend has been the development of combined PA and NP programs (also known as APP programs). Such APP programs enroll both PAs and NPs and are thought to exist in settings that employ both PAs and NPs in similar clinical roles. Although published data from 2011 indicated that only a small minority of resident programs included both PAs and NPs, a very small sample (13) of the APPAP program membership conducted in 2015 indicated that over 40% of the programs also accepted NPs. Although this available data is quite limited, the authors believe that more PA/NP programs are developing and anticipate this trend to continue.


Program leadership and instructors


PA residency programs are typically led by a PA clinically practicing the specialty and, less frequently, by a physician. Programs that enroll both PAs and NPs may be led by either or both. Instructors for residency programs typically consist of PAs, physicians, and NPs. 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.


Curriculum


Most programs are located in large academic health care settings that can provide a wide variety of patient care experiences and a diverse patient care mix. 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 variety of clinical experience for the PA. In addition to required clinical rotations within and outside the program’s discipline, most programs also offer clinical electives to allow the PA resident opportunities to structure their training around their unique professional interests.


The number of clinical hours required by programs is thought to vary considerably between programs and specialties. Nevertheless, limited published data are available, although some programs provide this information on their website. Often residencies, including surgical programs, require clinical hours well over a standard 40-hour work week. In-house call is required for many programs, although previous studies have found considerable variability, ranging from 31% to more than 60% of programs reporting that they require inpatient call. , With the work hour restrictions imposed for physician residents, it is likely that PA residents adhere to similar restrictions. Former ARC-PA accreditation standards required work-hour restrictions for PA residency. Programs accredited in the future will likely be required to adhere to such restrictions.


In addition to clinical training, programs provide formal didactic instruction at the beginning of the residency, incorporate instruction 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


Most PA residency programs currently offer a certificate upon completion of the program (similar to a physician residency program). In earlier years, some programs awarded academic credit or master’s degrees along with certificates. The first PA specific clinical doctorate degrees were obtained by PAs participating in military residency programs. In 2006 the U.S. Army Emergency Medicine PA residency program expanded its program from a 12-month program to an 18-month program, incorporating formal, online coursework into their training. This was a unique collaboration with Baylor University in Waco, Texas, to award a Doctor of Science in PA Studies (DSc). Since that time, additional military programs have begun offering a DSc with six programs described in a 2011 study. In 2018, the first doctorate degree available to civilian PA residents was observed. A Doctor of Medical Science (DMS) can now be earned by completing online courses and participating in a resident program within the local health care system or in other residencies affiliated with the university. Given the recent interest in clinical doctorate degrees by many PAs, additional opportunities for PA residents to earn doctorate degrees are anticipated to develop. It is unclear at this time, however, if the awarding of doctorate degrees in partnership with PA residency programs will become a widely adopted model.


Compensation and benefits


Compensation is provided to PA residents with most programs, similar to physician residencies, providing an educational stipend in addition to fringe benefits. Although some programs list compensation information online, comprehensive data on compensation rates across programs are not available, and unlike with physician residents, compensation varies widely by program. Data from 2011 indicated 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. Given the continued increasing salaries of PAs in clinical practice in recent years, it is likely that PA residency stipends have continued to increase. Benefit packages also vary but generally include such items as health insurance, malpractice insurance, paid vacation time, and sick leave. ,


The impact of physician assistant residency programs


Over the years, some of the most important questions asked about PA residency training have included the potential value of such programs for participants, what impact these programs have and will have on PA practice, and whether program accreditation will be beneficial or could in some way be detrimental to the PA profession. Despite these broad questions, relatively little research has been conducted regarding PA residency programs, particularly in recent years.


The number of PAs that have undergone training in postgraduate residency programs has been difficult to determine. 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. Therefore the impact of residency training broadly on PA clinical practice is not thought to be substantial, and studies comparing PA resident graduates with PAs who did not participate in residency training have not been conducted. Given the very small number of residents and the many factors that impact quality patient care, such studies are likely not feasible. Although anecdotal evidence exists to suggest that graduates may be more likely to provide clinical teaching and professional development (such as through speaking at professional conferences or through assuming leadership roles), studies are needed to explore this further.


Residency graduate employment opportunities


Reports confirm that most graduates go on to practice in the specialty of their training, and several reports indicate that they are highly competitive candidates for these positions. One study and substantial anecdotal reports found that residency-prepared PAs have a competitive edge over nonresidency-trained PAs when applying for PA positions. Little objective information has been published comparing the number of employment opportunities and the salaries commanded between residency-prepared and nonresidency-prepared PAs. One study published in 2007 surveyed PAs in surgical settings, comparing graduates from surgical residencies with those who had not received such training. The mean salary per hour was similar between the two groups. Although some graduates may receive higher initial compensation, no data suggest that there are long-term financial advantages to residency training.


Resident perceptions of training


As previously discussed, because PA residency training is not required for PA practice, PAs may choose to enroll in residency programs for various reasons. The most common reason PAs decided to pursue residency training appears to be to enhance their competitiveness for jobs in their desired specialty. Another important reason is the desire of PAs to expand their current level of competency in the specialty, either to obtain additional clinical knowledge and skills before going into practice or to enhance their ability to change specialty. Studies have shown that graduates perceive that they are more competitive within the job market. Furthermore, graduates also report increased confidence and autonomy after residency training. , Overall, studies have found that graduates are generally very satisfied with their training and would recommend their program to other PAs interested in the specialty. ,


Few disadvantages to residency training have been reported. The primary one is the lower stipends received by PA residents compared with PA salaries in the workplace. Of interest is a study published in 1987, which found that a small percentage of graduates perceived that they were actually overprepared for their job. Nevertheless, as the scope of practice for PAs has expanded since that time and because more recent studies have not investigated this issue, it is unclear if this remains a concern of some graduates.


Included in this chapter are interviews with three PAs who attended or are currently enrolled in a residency. The interviews explore their perceptions of their residency experience and their reasons for electing to attend a residency program.


Employers’ perceptions of graduates


Although some studies have explored the impact of PA graduates, little is known about the perceived value of PA residency training in the workplace. In 2015 the AAPPA commissioned a Task Force on the Accreditation of Postgraduate Training Programs. The results of their work was described by Hussaini et al. in 2016. The task force conducted interviews, focus groups, and surveys with key stakeholders. Participants included health care employers, managers, and physician leaders from diverse geographic and clinical specialty sites. Employers and managers noted the increased confidence of PA residency graduates but also reported that well-designed onboarding programs were equally effective in preparing PAs for clinical practice. Few hiring managers preferred hiring new graduates. Most physician leaders indicated that they valued experience from PA residency programs, although some preferred to train their own PAs. Physician leadership identified a variety of competencies that PA residency graduates displayed related to systems-based practice, clinical research, interprofessional and multidisciplinary practice, and leadership.


Information for potential applicants


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 on their website ( www.appap.org ) and links to programs’ websites are available on this site. A web search for other programs can help potential candidates identify additional programs. PA specialty organizations, such as the American Association of Surgical Physician Assistants and the Society of Emergency Medicine PAs, may also be a valuable source of information regarding residencies in a specific specialty.


Most students consider additional training when they are in PA school. 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 provided by residency programs to PA schools. Nevertheless, many PA residents and students report that they did 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. ,


Admission to residencies is thought to be 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 indicates 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.


Selecting a residency program


Residents historically indicated that the way they learned about the residency program was either through information provided by the PA program they attended or from a student or residency graduate. Online information is now available for most programs.


Potential candidates should consider certain factors when examining the program curriculum, including the clinical experiences and didactic instruction provided and program goals. Candidates should be informed regarding policies related to graduation requirements, work hours, evaluation and remediation, and benefits. If such information is not published or provided during the interview process, candidates should request this information from programs to ensure they have a clear understanding of program expectations.


Current program residents and recent graduates may provide a unique perspective and they may be available to speak to applicants about their experience in the program. Because most programs require an onsite interview, this provides candidates with an opportunity to meet the program leadership, instructors, staff, and current residents; tour clinical sites; and learn more about the program at that time. If an onsite interview is not required, candidates may wish to consider arranging a program visit on their own to learn more about the program onsite.


Admission requirements


Admission requirements are typically published online by each program. All programs require PA residents to have graduated from an ARC-PA entry-level PA program and most require that they be certified by or eligible for the 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. PA students wishing to enroll in a residency program after PA school should apply to programs before they graduate. Students should also consider participating in an elective rotation within the discipline of their interest during PA school.


Case studies



Jun 15, 2021 | Posted by in MEDICAL ASSISSTANT | Comments Off on Postgraduate clinical training programs for physician assistants
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