20 Years: The Evolution of the Physician Assistant Profession

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The expansion in the last 20 years illustrates the rapid proliferation of PA training programs.
The expansion in the last 20 years illustrates the rapid proliferation of PA training programs.

The physician assistant (PA) profession has evolved significantly throughout the past 20 years. To say the face of the profession has changed is true on many levels. Some changes have been due to internal forces and a natural progression. However, other changes can be linked to external transformations within the healthcare environment.

The growth curve of the number of PAs has been remarkable during the past 2 decades. According to the American Academy of Physician Assistants (AAPA), in 1998 there were 41,000 graduate PA programs.1 Compare that with the 123,000 programs in the United States in 2017.2 The expansion in the last 20 years illustrates the rapid proliferation of PA training programs. In 1998, there were 110 accredited PA programs.1 That number has quickly ballooned to 229 programs presently, with many candidates applying each year for provisional accreditation.3 The increase in PA training programs can be attributed to many factors. The projected demand for PAs, combined with the increasing number of PA applicants, has helped fuel the growth. Furthermore, there has been increased awareness of the PA profession, which has been recognized as one of the best careers by Forbes and US News & World Report.4,5 The growth in PA income has also leveled out, suggesting that the supply of PAs is outpacing the demand.6,7 Another number that has grown during the past 20 years is the cost of attending a PA school. The tuition I paid for PA school in 1999 is markedly less than the going rate for PA school tuition in 2018. 

Rules and regulations

The rules and regulations that govern PAs have also changed with the emergence of Optimal Team Practice (OTP). In 1998, PAs could only prescribe in 44 states, Guam, and Washington, DC.1 Today, PAs can prescribe in every state, and the concept of the PA profession has spread to multiple other countries. The AAPA and many state PA organizations took the next step to allow PAs to practice at the top of their license and fully increase access to patient care by supporting OTP. Although the details of OTP are open to interpretation, the fundamental recommendations include:

  • Allowing PAs to practice without an agreement with a specific physician—enabling practice-level decisions about collaboration
  • Creating separate majority PA boards to regulate PAs, or give that authority to healing arts or medical boards that have as members both PAs and physicians who practice with PAs; and
  • Authorizing PAs to be directly reimbursed by all public and private insurers8

These changes are controversial. Some see OTP as a departure from the roots of the PA profession, as independent practice, or as PA autonomy that is evolving with the changing healthcare environment. Regardless, some state PA organizations have successfully implemented aspects of OTP into their PA state scope of practice regulations. 

The average PA has changed

Throughout the last 20 years, we have seen an increase in the proportion of PAs who are women.3 We have also seen the average PA student become younger but have a higher GPA. I am often shocked at the average GPA of the PA student applicant and say a silent prayer of gratitude that I applied in the 1990s! PA students are also tech-savvy. I think back to the days when my white coat was so heavy from multiple Scut Monkey books and notes in my pockets that my shoulders hurt at the end of each rotation day. Now, these Apple Genius Bar PA students carry volumes of materials in tiny electronic gadgets and smile at me gently when I ask them to show me how to use Venmo to donate to their class fundraiser. With that, I see PA students accept electronic health records with ease. They balk at handwriting patient notes. On the other hand, I have seen PA students with higher anxiety over performance in PA school, and they have a much tougher time accepting a minor “failure” and moving on. 

Overall, PAs are satisfied with their career, and most PAs would recommend their career.9 However, anecdotally from my friends and on social media PA groups, I see more burnout. Some of it is related to the changing face of health care more than to the role of the PA. There are more posts about the pressure of Press Ganey scores or the hurdles of payers dictating what therapy a patient may have than PA-specific posts. I do see PA-specific posts mostly expressing dissatisfaction with finding a good, honest, fair, collegial, supportive supervising physician who appropriately compensates their PA. As more physicians move from practice owner to hospital or healthcare system employee, we see the face of the supervising or collaborating physician change as well.

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