PA Employment and Supervisory Laws

The SARS-CoV-2 pandemic highlights the need for clinicians to address increased medical demands across the United States (US). The clinician shortage in the US has been reported for several years and is projected to worsen.1 Both PAs (physician assistants) and NPs (nurse practitioners) are essential in meeting the demand for increased access to healthcare in the US.2 However, anecdotal reports voiced and written on PA forums indicate that PA employment opportunities have been declining in recent years and have further declined in the early months of the SARS-CoV-2 pandemic.

This is a pilot survey conducted at a crucial time to evaluate perceptions of PA employment as well as employment opportunities amidst the SARS-CoV-2 pandemic. This report outlines data from practicing PAs regarding their job opportunities, the effect of the pandemic, and speculated causes of reduced employment opportunities. One recurrently reported cause of PA job decline is supervisory laws. Qualitative and quantitative data were analyzed regarding employment variances experienced by PAs and perceived root causes including barriers to PA employment, including legislative statutes.

Methods

Research approach

A brief thirty-question survey was instituted to evaluate the employment experiences of practicing PAs. The survey included questions regarding demographics, experience level, employment opportunities, and perceived causes of the participants’ reported experience using a combination of binary, multiple-choice, Likert scaled, and open-ended questioning.

Participants

Practicing PAs who live and work within the US were included in this study. PA students and non-PAs were excluded from the survey. The survey was disseminated to practicing PAs utilizing online PA-only platforms, such as the AAPA Huddle, and formal emails from the primary investigator to four PA programs to be disseminated to alumni.

Data collection

The survey was distributed on June 30th, 2020 with participant responses recorded through midnight July 30, 2020, using Google Forms.

Data analysis

Data was compiled in a Google Sheets file, then exported for evaluation using Stata 16.1 MP software for statistical analysis. Additionally, thematic content analysis was used to uncover recurring concepts by text-scrubbing the open-ended questions using the software.

Ethical consideration

The survey was approved by the University of Lynchburg Institutional Review Board. Participants gave informed consent, and their participation was voluntary. No reimbursement was made to participants.

Results

Demographics

A total of 1566 participants were surveyed from the various platforms. This accounts for 1.12% of all practicing PAs in the US.3,4 Participants represent a population from diverse geographic locations, specialty areas, and experience levels. The survey sample means are similar to the National Commission on Certification of PAs (NCCPA) population proportions identified in the 2019 Statistical Profile.4 Specifically, the five states with the highest percentage of participants were: New York (9.62%), Texas (7.65%), Florida (7.71%), California (6.76%), and Pennsylvania (5.36%). Again, congruent with NCCPA national averages, the participants working in primary care (family, general, or internal medicine and pediatrics) accounted for 26.77% of total responses. The mean distribution for experience level was 10.76 years (95% CI [10.34, 11.18]) as a practicing PA. The experience level of the respondents ranged from one year to greater than forty years as a practicing PA.

Loss of employment

Almost half of the participants (44.44%) reported experiencing a detrimental employment outcome due to the SARS-CoV-2 pandemic (Figure 1). Of those reporting a decline in employment status, more than a quarter (26.83%) report the loss of employment was attributed to their state’s PA supervisory laws.

The geographical regions (US Census Divisions) with the highest reported detrimental employment outcomes were the South Atlantic division followed closely by the East North Central division with 50.42% and 50.00% of respective participants indicating loss of employment during the SARS-CoV-2 pandemic (Table 1).5

Evaluating the top five respondent states for detrimental employment outcomes by years of experience suggests a relatively uniform distribution (Table 2). Out of the 44.44% of participants who reported detrimental employment outcomes during the SARS-CoV-2 pandemic, those with 1-3 years experience were most affected at 29.5%. However, years of experience as a PA were not statistically significant regarding loss of employment during the pandemic (chi2(5) = 6.124, p = 0.294). 

Figure 1. Did you receive a detrimental employment outcome* due to the SARS-CoV-2 pandemic?
Participant Breakdown by US Census Division
U.S. Census DivisionsParticipants% Job Loss
East North Central10.5850.00
East South Central4.0242.86
Middle Atlantic17.4635.77
Mountain8.0940.94
New England9.6241.06
Pacific11.9847.34
South Atlantic22.8250.28
West North Central5.1043.75
West South Central9.8843.87
Table 1.  The percentage of participants from each U.S. Census Division is listed in the middle column.9 The percentage of respondents from each division who reported a detrimental outcome due to SARS-CoV-2 is listed in the right column.
Detrimental Employment Outcome due to Sars-Cov-2
    Years of
PA Experience
CaliforniaFloridaNew YorkTexasPennsylvaniaAll states
4 or less51.52% (33)42.42% (33)26.00% (50)33.33% (18)31.03% (29)40.92% (435)
5 to 959.09% (22)55.17% (29)44.00% (25)48.48% (33)37.50% (24)48.48% (363)
10 to 1439.29% (28)68.00% (25)27.27% (22)34.38% (32)28.57% (14)43.48% (322)
15 to 1943.75% (16)55.00% (20)34.62% (26)50.00% (12)60.00% (5)47.12% (208)
20 to 3950.00% (6) 50.00% (12)40.00% (25)52.17% (23)36.36% (11)42.72% (213)
40 or more100.00% (1)100.00% (2)66.67% (3)50.00% (2)100.00% (1)52.17% (23)
Table 2.  Percentage of participants by state who experienced a detrimental employment outcome* due to SARS-CoV-2 pandemic. (n = total number of respondents).

Supervisory laws

Participant’s report being disadvantaged for employment opportunities (chi2(1) = 52.9883, p < 0.0001), and being explicitly told they were disadvantaged for employment by potential employers due to PA supervisory laws (chi2(1) = 25.4884, p < 0.0001). More than three-fourths of participants (76.87%) report that supervisory laws place them at a disadvantage for employment opportunities during their career as a PA (Figure 2). Of surveyed PAs, 58.00% report that PA supervisory laws are highly restrictive, while 34.99% are neutral on the subject and 7.01% reported that supervisory laws are not restrictive.

Respondents in primary care fields are more likely than those in non-primary care fields to report disadvantages from legislation (81.86% compared to 75.04% respectively, chi2(1) = 8.0146, p < 0.005). Specifically, participants practicing in primary care report supervisory laws increase barriers to practice compared to those in specialty areas (chi2(2) = 5.1908, p = 0.075). In primary care, 43.20% of participants were explicitly told they were disadvantaged due to supervisory laws while 32.76% of participants reported this in non-primary care fields (chi2(1) = 14.5173, p < 0.0001). 

Notably, there is a positive correlation between years of experience and feelings of restriction by current PA regulations.  Participants with greater years of PA experience indicate that supervisory laws are statistically more restrictive than less experienced PAs (chi2(10) = 44.763, p < 0.0001).

Surveyed PAs reported being explicitly told they were unqualified for hire due to supervisory laws 35.58% of the time, with 67.39% of these individuals hearing this sentiment on more than one occasion. 

Figure 2. Responses from participants to the following question: In your career as a PA, have you ever felt you were at a disadvantage for employment opportunities because of PA supervisory laws?

Themes

Text scrubbing identified knowledge about the PA profession as the most common theme with more than two hundred mentions from participants. Other recurrent themes include job security, legal concerns, marketing, and PA title change. Patient care concerns were also identified more than one hundred times in the open-ended responses.

Discussion

This pilot study suggests that participants perceive overall disadvantages in PA employment opportunities. Detrimental employment outcomes were reported at elevated rates during the SARS-CoV-2 pandemic. Experience level and loss of employment were not statistically significant between primary care fields and non-primary care fields. Participants report detrimental employment outcomes due to the SARS-CoV-2 pandemic in all specialty areas, experience levels, and states. 

The open-ended survey questions suggest several underlying causes including lack of knowledge about the PA profession, inaccurate title, and supervisory laws. This suggests that the decline in PA job opportunities may be multifactorial. Participants in various fields reported that supervisory laws contributed to their detrimental employment outcome. Numerous participants voiced concern about PA legislation being outdated or misaligned from current practice in the open-ended responses. Interestingly, participants were explicitly told they were unqualified for a position due to PA regulations at different rates between primary and non-primary care fields. The data suggest that supervisory requirements create a barrier to PAs in the marketplace. Data also indicate that supervisory laws are felt to be more restrictive by participants with greater years of experience.

Policy Implications

If supervisory requirements are playing a role in PA employment loss as these pilot data suggest, then without modernization of PA legislation PAs will be unable to meet the demand and the clinician shortage may be further exacerbated. Misunderstandings about the PA role appear widespread in both public and healthcare sectors including physician groups, nursing, and administration. As the medical landscape continues to adapt, legislative changes such as AAPA’s Optimal Team Practice (OTP) initiative become invaluable.6 The temporary suspension of PA restrictions in some states during the SARS-CoV-2 pandemic gave PAs the opportunity to practice at the top of their scope, medical training, and experience.7 Making these suspensions permanent may improve PA employment opportunities and thereby increase patient access to healthcare. 

As noted in the research findings, years of experience is correlated with reports that PA laws are too restrictive. The Model Legislation for PAs written by AAPA describes the importance of a PA’s scope of practice being established within the employment organization to account for experience level.8 Autonomy is not automatic, but instead ought to take experience and education into account. PAs are highly trained and equipped for medical practice.6 Removal of supervisory laws will enhance PAs’ abilities to continue to provide excellent care and improve patient’s access to healthcare within the US.9,10

Limitations

Selective sampling inherently limits data but carries value during rapidly changing events such as a pandemic. Network effects in distribution may skew results. The response rate to this survey could not be calculated due to the broad distribution approach on AAPA Huddle. Therefore, the authors acknowledge the potential for error. Similarly, appropriate statistical survey weights could not be derived to accurately transform the data to be fully representative of the national sample, therefore NCCPA 2019 data was utilized.

Administrators, NPs, and physicians were not included. Their responses in future studies may inform the reader of additional information that this data lacks. It may be informative to determine if NPs and physicians also experienced increased layoffs during the SARS-CoV-2 pandemic. As well as a follow-up to determine how many were able to return to their former position versus those who had to move onto new employment. Additionally, there may be concerns from practicing PAs that deserve greater research than this survey provided. 

This research provides suggestions about current PA employment opportunities and should be used to validate the need for additional research regarding PA employment, education about PAs, and state supervisory regulations. Future studies should seek to utilize a more discrete distribution method and consider oversampling certain states and clinical areas would allow for more accurate national representation from the sample and would allow the derivation of statistical sample weights.

Future Research

Comparative analysis of physician, healthcare administrator, and employer perceptions of PA employment may be more indicative of the root problems in PA hiring. US Bureau of Labor Statistics data indicates that employment opportunities have increased for NPs at double the rate of PA positions.3 There may be a correlation between the self-reported decline in PA job opportunities and the objective growth rate of NP positions disproportionate to that of PA positions. Additional studies are required to fully evaluate this claim. Furthermore, research comparing states with the modernization of PA practice laws to states without modernization would contribute to an understanding of how PA legislation objectively affects PA employment opportunities.

Conclusion

PAs serve a crucial role in improving patient access to healthcare. This data indicates that participants attribute a decline in PA employment opportunities to state legislative restrictions, which was exacerbated by SARS-CoV-2 in many states. Supervisory laws may be reducing patient access to care across all states and specialties. Participants suggested that the PA profession should seek to remove these practice barriers and better educate employers and the public to keep the PA profession viable in a constantly evolving healthcare landscape. As the clinician shortage in the US continues to worsen, barriers to PA employment will further exacerbate patient access to care.

Special Thanks

Thank you to Jonathan Baker, Jennifer Mayer, Mike Sacks, and Desmond Watt for your contributions! This would not be possible without all of your help!

Echo Kopplin, DMSc, PA-C
Echo Kopplin, DMSc, PA-C

Dr. Kopplin has been practicing family and emergency medicine for four years. She currently resides in Lincoln, NE. She is active on the Nebraska Legislative Committee as Vice Chairman and enjoys working with pre-PA and current PA students to encourage PA advocacy.

References

  1. Tim D, Ryan R, Chakrabarti R, Jones K, & Iacobucci W. The Complexities of Physician Supply and Demand: Projections from 2018-2033. AAMC. 2020. Retrieved from https://www.aamc.org/data-reports/workforce/data/complexities-physician-supply-and-demand-projections-2018-2033
  2. Hooker RS, Brock DM, Cook ML. Characteristics of nurse practitioners and physician assistants in the United States. JAANP. 2016; 28(1): 39-46.
  3. U.S. Bureau of Labor Statistics. Occupational Employment Statistics. Updated June 8, 2020. Accessed August 9, 2020. https://www.bls.gov/oes/tables.htm
  4. National Commission on Certification of Physician Assistants, Inc. (2020, April). 2019 Statistical Profile of Certified Physician Assistants: An Annual Report of the National Commission on Certification of Physician Assistants. Retrieved August 10, 2020, from http://www.nccpa.net/research
  5. U.S. Census Bureau. Census Regions and Division of the United States. Accessed August 21, 2020. Retrieved from https://www2.census.gov/geo/pdfs/maps-data/maps/reference/us_regdiv.pdf
  6. American Academy of PAs. Optimal team practice. https://www.aapa.org/advocacy-central/optimal-team-practice/. Accessed August 30, 2020.
  7. American Academy of PAs. COVID-19 State Emergency Waivers. https://www.aapa.org/cme-central/national-health-priorities/covid-19-resource-center/covid-19-state-emergency-response/ Accessed October 10, 2020.
  8. American Academy of PAs. Model State Legislation. https://www.aapa.org/wp-content/uploads/2017/02/Model_State_Legislation_May_2016-1.pdf Accessed August 30, 2020.
  9. Timmermans MJC, van Vught AJAH, Peters YAS, et al. The impact of the implementation of physician assistants in inpatient care: A multicenter matched-controlled study. PLoS One. 2017;12(8):e0178212. doi:10.1371/journal.pone.0178212.
  10. Hooker RS, Everett CM. The contributions of physician assistants in primary care systems. Health Soc Care Community. 2012;20(1):20‐31. doi:10.1111/j.1365-2524.2011.01021.x. 

One comment

  1. Bibi

    Excellent!!
    By Doctor Kopplin!!
    I have 20 plus years of experience in many specialities and in all these years I anticipated everything which is pointed out in this article. I faced all the above and still facing. This was the best profession but unfortunately our organization failed to give us any support snd protection. We are still struggling for the name change.
    We will be EXTINCT and will be EXTINGUISHED if we won’t smell the coffee and wake up.
    We got to change the name and we got have our independence without the clutches of physician’s co-sign or collaborative agreement. We got to recognize and be acknowledged as the doctor of General Medicine (DGM) if we want to survive.
    Our profession needs full name change, independent authority and more training snd our experience years must be counted towards our independence.
    If we won’t be able to achieve all the above in near future, We are No more.
    Thank you…..

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