Physician assistants (PA) are number #1 in healthcare, so getting a job for an experienced PA should be super simple. Right? Maybe not always. My personal awakening to the looming problems in the physician assistant profession came in 2018. I had always enjoyed an easy time finding a position, and with an upcoming out-of-state move, I expected nothing less. I applied, however, to over 50 PA/NP jobs with few responses.
Many of the jobs required a state license to apply, so I had difficulty making it past computer algorithms and human resource screeners. This was because antiquated legislative laws dictated that I have a supervising physician in order to acquire a state license. In essence, it was an endless cycle wherein I could not apply for a job without a state license, but I couldn’t acquire a state license without a job. As I began to wonder what I was going to do for a job, I realized that physicians and NPs did not have this same mandate. It awakened me to the grave realization that the PA profession was not competitive in my new environment.
Exit… Stage Left
I eventually decided that if I couldn’t readily get a job as a PA, I would need to maneuver into another profession. Nurse practitioners (NP) and physicians have professions that are flexible enough that they can readily pivot into other professional roles, such as education, research, pharmaceuticals, medical malpractice expert, and medical writer. Although PAs can be found in all of these roles as well, there are relatively few PAs, in both number and percentage, that leave clinical practice in comparison to nurses and physicians.
I personally decided to fall back on teaching at the collegiate level-something I had been doing on the side for the past decade. Even in academia and with my experience, I had difficulty finding an academic placement due to the relative lack of PA schools in my metropolitan area. As I was forced to compete for general biology undergraduate positions, my stiff competition was likely from masters-level high school biology teachers.
Generalizing the Generalist
In general, PAs are excellently trained to provide competent, exceptional care to the most vulnerable and fragile in our society. Healthcare employers, however, have difficulty fully understanding a PA’s capabilities, so it is little surprise that the larger populace has no working construct for the PA. As a result of all this, I came face to face with the challenges of being able to pivot into other roles. I had difficulty transitioning into academics, recruiters for clinical research told me that PAs were too risky for their market clientele, and administration wouldn’t consider my underwhelming administrative working experience and education. My training in clinical medicine was excellent, but it did not equip me for job mobility. Unfortunately, I fear PAs will increasingly try to row this same proverbial boat when clinical PA positions become increasingly scarce.
Roughly half of PAs have been in practice for seven years, meaning that a majority of the profession has substantial student loans and a long career ahead. There is dire news for PAs that fall into this category. Our profession may not last long enough to pay-off those substantial loans, much less last the entirety of their professional career. There are a few reasons why our profession may be headed for rough days.
APP Jobs will be dominated by NPs
Consistent with nurse practitioners’ objectives of “meeting the existing and future primary care needs of our nation”, all sectors of healthcare will be dominated, if not completely run, by nurses and nurse practitioners within ten years. As a little background; nurse practitioner numbers were projected to increase a staggering 130% between 2008 and 2024, with a projected NP workforce of 198,000 by 2024. There is projected to be a surplus of primary care nurse practitioners by 2025, with 13 states boasting an oversupply of primary care NPs by 2025. A 2015 Monthly Labor Review article goes on to state that registered nurses and nurse practitioners “are projected to add the newest jobs and grow the fastest” from 2014 to 2024.
The projected nurse practitioner numbers were wrong, as there are already more than 290,000 nurse practitioners in 2020. In comparison, the PA profession is expected to increase by 72% by 2025. The increase in primary care PA supply is also projected to exceed demand by 2025 but to a lesser extent. With full practice authority for NPs, the squeeze for jobs will be much harder felt for PAs than NPs. This is because it is cheaper and easier to hire an unrestricted NP than it is to hire a PA plus a supervising physician. There is then the added administrative work of finding a physician to supervise a PA hire.
Legislative Restrictions Will Limit PAs
In addition to the NP surplus problem for the PA workforce will be the administrative disparities between NPs and PAs. NPs have full practice authority in 24 states and are legislatively close to achieving it in an additional 16 states. Much has been said about training and educational comparisons between the three types of providers, but in the end, this is just a distraction from the numerous studies showing the most important issue of outcomes, for which the professions are similar. The truth is that healthcare employers hire nurse practitioners and PAs because of their financial appeal.
Healthcare is a Business
Who is “best” for the job is, and has always been, financially driven. The most cost-effective, least burdensome provider will win. When physicians largely ran medicine, burdens of supervision, malpractice risk, and administrative issues were par for the course, as NPs and PAs provided competent care, increased revenue profits, and had a similar scope of practice. Now that physicians are no longer making a majority of the financial decisions for healthcare, they likely don’t want to be saddled with these burdens. Administrators arguably don’t want the burden either. In essence, PAs maintain financial appeal but are increasingly less desirable than our legislatively unrestricted NPs. The following NP perspective is acutely accurate.
“PAs are not allowed to practice independently of the physician, but an NP may have authority to diagnose, treat, and prescribe without physician supervision. Thus, when NP [scope of practice] SOP is broader, NP capabilities are closer to those of a physician and PA capabilities are more limited when compared to an NP’s.”
When given a choice, the unrestricted provider will always be a more desirable hire.
NPs Will Shift into Surgery and Specialties
PAs’ footprint in primary care is already shrinking and this shrinkage will likely seep into all specialties over the next ten years. Likely, this is due to two main issues. First, the primary care surplus NP issue likely pushes restricted PAs and expensive physicians out of the primary care marketplace. Second, PAs have legislatively mandated tethers to physicians. Simply stated, even if NP oversupply wasn’t an issue, lack of supervising physicians in primary care inadvertently forces tethered PAs into the specialties where physicians are located.
Once oversupply in primary care becomes problematic for NPs, they will likely work to increase job opportunities for their profession via certifications, legislation, and advocacy. A realistic projection is that once NPs have dominated the primary care sector by 2025 and oversupply becomes a problem, unrestricted NPs will spread into surgical and specialty positions via an RNFA certificate, further reducing the PA footprint. A 2018 study showing that employment of specialty NPs grew at a 13% faster rate than the employment of PAs from 2008 to 2016 leads credence to this. By this, NPs will bleed into specialties and continue to push out PAs from their already marginalized areas of practice, and they will do it with an unrestricted license. This will further decrease the PA footprint in medicine.
New Frontiers for Physicians
Telemedicine is another nail in the PA professional coffin. Physicians have an Interstate Medical Licensure Compact system, which makes it significantly easier to obtain licenses in multiple states. Adding this to their unrestricted licenses, physicians are currently seeing a boom in telemedicine jobs. NPs and PAs do not have this compact. However, NPs do have a Nurse Licensure Compact and are working to expand this for their NP counterparts. Without such compacts, the wait time and difficulty in acquiring multiple licenses are costly and time-consuming.
For PAs, the requirement for physician licenses and physician supervision costs must be added to this administrative licensure headache. The logical outcome is that PAs are not desirable candidates for telemedicine. Considering the explosion of telemedicine with the pandemic and its projected exponential growth over the next ten years, the financial incentive to hire an NP, their independence in about half of the states, and the developing NP multistate licensure compact, PAs will have increasing difficulty finding work in telemedicine.
Physician Assistants vs Assistant Physicians
Perhaps the final blow for the PA profession will be from unmatched international medical school graduates (IMG). Every year, thousands of medical school graduates (mostly foreign) are unable to place in US residencies. These graduates have created a niche license known as the assistant physician (AP). Just as the name is similar to physician assistants, these assistant physicians work in much the same way. APs must have a collaborative agreement with a licensed physician and have varying degrees of physician delegation based on the state and terms with the collaborating physician.
Missouri passed legislation allowing for these IMGs to practice back in 2014. Since then, Arkansas, Kansas, and Utah have allowed some form of license for these graduates despite troubling USMLE scores from this group of poor residency candidates. They are considered physician assistants for reimbursement purposes but don’t need to have passed the Physician Assistant National Certifying Exam (PANCE), need a named collaborating physician, or need to list their practice type. With an average compensation of $48,381 in July of 2019, there are considerable concerns about salary competition with NPs and PAs.
What Can We Do?
Fear is a powerful force. My four-year-old daughter has struggled recently with confidence in swimming. She completed infant-swim-rescue (ISR) training last year and is a capable, albeit inexperienced swimmer. On a recent swimming trip, she would have drowned in a pool for nothing more than her paralyzing fear that she couldn’t do it. PAs are experiencing their own version of drowning. PAs are a proven, capable profession, but many are admittedly afraid physicians will start negative campaigns if PAs ask for legislation that reflects clinical practice. Others are simply afraid of failure.
Most don’t understand that fear is not an inherent problem. However, how individual PAs handle this fear repeatedly will determine our professional fate. Failure to act is still a failure. Failure will occur and is a necessary ingredient for success. The only way to overcome this fear is to develop the winner mindset, with the understanding that failure will occur, can be overcome, is necessary, and is rooted squarely on the path to eventual success.
Overcoming Fear and a Fixed Mindset
For my daughter, overcoming fear meant returning her to an ISR refresher course. For the PA profession, it likely means submitting legislation that may have negative physician reception or pushing for legislation that may initially fail. Are we ready, as a profession, to embrace our upcoming failures on the road to success? Or, more importantly, have PAs yet decided whether they want the PA profession more than their fear of failure?
The biggest issue with professional advancement, in this author’s opinion, is the mindset of pre-PAs, PA students, and early career PAs. As a pre-PA, I was delighted to know that someone else would be ultimately in charge of my care decisions, due to personal fears of failure with someone’s life. These ideas were uneducated. For every patient that a PA encounters without a supervising physician physically present, that PA is providing autonomous care.
PAs are held to the same standard–let’s rise above it.
Any experienced PA could explain that PAs are required to be as competent and capable as their physician counterparts and are held to the same legal standards of care as physicians. This is born out of the legal mandate requiring equal standards of care for physicians, PAs, and NPs. Because we are legally required to be equal in our care standards and research studies show equal care outcomes, we need to as a profession embrace and promote our achievements and abilities.
Support Our Professional Organizations
Own this responsibility. Push for legislation to reflect it. Demand our organizations promote it. The profession started out as someone’s assistant, yes, but it quickly evolved from that role. Recent studies reveal that 76% of PAs currently clinically practice autonomously. It is time to start pushing legislation similar to North Dakota, Minnesota, and Maine. Asking for PA legislation to mirror PA clinical practice is nothing more than asking for the legal authority to do what we are already doing.
Should PAs be restricted with mandated physician oversight? In short, no. If for no other reason than to allow patients better access to competent, capable providers, PAs should not be restricted. All providers should be allowed to work at their fullest capability to provide care for our patients. NPs understand it. Physicians fear it. The US government acknowledges it. It is time for PAs to stop our professional infighting and push for legislation to keep a better pace with our training and professional skills.
From this, it becomes evident that we must modernize our professional views relative to physicians. PAs must continue to clinically collaborate with all healthcare entities. We must stop desiring physician agreement with the PA profession. PAs need to acknowledge that they already provide quality care in the absence of a physical physician presence in the patient’s room. PAs need to take leadership positions and push for legislative advancements that reflect current clinical practice.
This leads to the inevitable issue of the PA title. Many PAs, likely due to our historical origin, are just fine with our current title and feel that we simply need to market it better. This author contends that it is difficult, if not impossible, to market a lie. PAs do not assist physicians in their job duties. PAs perform the same job duties as physicians. The name is an oxymoron that creates confusion due to the fact that in no other profession does a subordinate do the actual job of the senior. Much research has concluded that PAs substitute for the physician in 85% of primary care tasks and produce the same productivity outputs as physicians in outpatient settings. The 15% difference likely has much to do with legislatively mandated restrictions on experienced primary care PAs.
PAs make medical treatment decisions for millions of patients per year. We perform in all levels of healthcare management, including medical director, chief medical officer, clinic owner, and CEO. PAs need to acknowledge our professional abilities, acknowledge that the name hurts advancements, acknowledge our excellent training, and advocate for a name change. PAs need to grasp the seriousness of how the PA title has hindered forward progression in states such as Ohio, Florida, and many others.
What then is to become of the PA profession? Only time will tell, but the likely outcome is that the PA profession will steadily become less favored in the healthcare marketplace. This may very well lead to the extinction of the PA profession. Will this happen in ten years? Given the above market forces, this is a conceivable outcome. What an interesting path it would be to go from number one to not at all. Changing healthcare preferences for one provider type over another can affect which occupations are employed in an industry. The good news is that PAs have not been pushed out of all job markets yet and several states are making headway with legislation.
There is a real foreseeable danger of being forced out of the profession when employment challenges and professional competition becomes fierce. My job search prior to the pandemic showcases this. The solution of moving to a PA friendly state or changing medical specialties may not be an option for everyone, as was the case for me. If any of this speaks to you, I suggest joining the effort for reform.