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Center for the Future of the Health Professions Sept. 2021 digest

The future of physician assistants is in the training

This month, The Center for the Future of the Health Professions is posting another monthly op-ed column for 2021. Our columns represent strong, informed, and focused opinions on issues that affect the future of the health professions. As mentioned in the past, the center was developed to provide state, local, and national policymakers and health system stakeholders with accurate, reliable, and comprehensive data and research about the healthcare workforce, so they can effectively plan for a sustainable future and make the best use of available resources.

This month features a discussion around the future of the education of physician assistants (PAs), particularly as it relates to recruiting, training, and placing PA students & graduates in our nation’s rural and underserved communities by Kim Devore, MS, PA-C, assistant professor; Michelle DiBaise, DHSc, PA-C, department chair & professor; and Tessa M. Tibben, DHSc, PA-C, assistant professor, Department of Physician Assistant Studies at A.T. Still University’s Arizona School of Health Sciences (ATSU-ASHS).

Twenty percent of Americans live in rural areas of the United States.1 These individuals tend to be older, with more significant health comorbidities, are mostly underinsured or uninsured, and are poorer than their urban counterparts.2,3 A rural health care crisis has emerged mainly based on lack of availability and accessibility; however, affordability, accommodation, and acceptability are also influential in this crisis.4 A 2018 Health Resources and Services Administration (HRSA) report revealed a health professional shortage of 66% for primary care and 62% for mental health services in rural or partially rural areas of America.3

Presently, 10% of physicians and 3.2% of physician assistants practice in rural areas.1, 5 This urban/rural gap is projected to widen by 23% by the year 2030, secondary to rural physicians aging into retirement and the reduced number of younger physicians replacing them within these communities.3 In line with this trend, one in five clinically practicing PAs are nearing retirement in the next decade.2

Alleviating the rural health care access crisis requires expansion of efforts beyond just physician recruitment to include recruitment of PAs. In 2019, the U.S. Bureau of Labor Statistics reported the number of PA jobs nationwide at 125,500 and a growth outlook of 31% between 2019-29.6 Moreover, PA programs provide a high-quality generalist medical education, priming the PA to practice patient-centered, collaborative primary care. Unfortunately, only 14.2% of all PAs practice family medicine, while 33% of PAs in rural communities practice family medicine.5 Most state legislation currently requires PAs to practice within their supervising physician’s scope of practice, further restricting how and where a PA can practice.7 Despite this, the increasing number of newly trained generalist PAs suggests that the PA workforce is well-positioned to help meet rural America’s growing primary care needs.2  

ATSU-ASHS’s Department of Physician Assistant Studies has a mission to recruit and train individuals from rural and underserved communities with the intent to increase access. The key to ATSU-ASHS’s PA program’s success in meeting its mission begins years in advance of the admissions process. Its partnership with over a dozen community health centers (CHCs) enables community leaders from rural, underserved communities to identify future PAs they believe have a heart for community health care. The ATSU Hometown Scholars program is designed to grant an automatic admission interview for any CHC-endorsed applicant who meets the minimum admissions requirements. Once selected to join the program, the student completes their didactic training at ATSU-ASHS in Mesa, Arizona, and returns to the endorsing CHC for 12 months of clinical training. Hometown Scholars has graduated 28 PAs in just the past six years, who now practice in their hometown, improving access to medical care. There are currently 17 more in the program.

Hometown Scholars is just one pre-admission strategy to meet ATSU-ASHS’s PA mission. Pipeline to Practice (P2P) is funded through a HRSA grant that partners with local undergraduate universities near ATSU-ASHS’s PA program CHC partners, recruiting future PAs with a heart to serve their local community. Like Hometown Scholars, P2P is designed to grant an automatic admission interview for any partner institution-endorsed applicant who meets the minimum admissions requirements. Moreover, like Hometown Scholars, the P2P student completes their didactic training at ATSU-ASHS in Mesa, Arizona, and returns to a CHC close to their endorsing institution for 12 months of clinical training.  ATSU-ASHS’s PA program faculty connect with these prospective students through presentations delivered during site visits to the region. Interested P2P candidates are associated with the local CHC to shadow PAs and other providers to learn more about healthcare careers. Often, these interactions lead to a Hometown Scholars endorsement.

The admissions process is another critical ingredient to ATSU-ASHS’s PA program’s success. Utilizing a rigorous multiple mini interview (MMI) process, students meet with several faculty, staff, and alumni across nine different interview stations. Topics discussed relate to underserved communities, social determinants of health, and PA practice ethics, allowing candidates to express their commitment to becoming a mission-match PA. Once accepted into the program, ATSU-ASHS’s PA program offers scholarships of up to $30,000 per year funded through a HRSA grant for economically or environmentally disadvantaged students. Students who otherwise would carry a lifetime of burdensome student debt are enabled to change the trajectory of their future and their community.

Once matriculated, PA students have several opportunities to work with underserved populations. Didactic clinical experiences during the first year include school physicals and COVID immunization clinics at Title I schools, intake interviews at substance abuse treatment facilities, health screenings at community outreach events, pre-and post-operative care at Mission of Mercy, and shadowing at urban area hospital emergency rooms. Students complete a minimum of eight experiences, but many will volunteer as often as possible. The experience in rural and underserved communities continues into the clinical year. Nearly two-thirds of the ATSU-ASHS’s PA program students complete their clinical training at a CHC campus. However, even the students who do traditional six-week rotations in the Phoenix area will be placed on rotations in rural or underserved locations.

ATSU-ASHS’s PA program is committed to recruiting, training, and placing graduates in our nation’s rural and underserved communities, working with the National Association of Community Health Centers. To date, the collaborative mission-focused efforts of the PA program have been very successful in meeting the needs of underserved communities. The program will continue to build recruitment funnels through Hometown Scholars and anticipates expanding success with the addition of the P2P program. However, barriers still exist in training and retaining graduates in rural areas. With the shortage of available providers board-certified in the specialty required for the rotation (i.e., board-certified pediatricians for pediatric rotations), ATSU-ASHS’s PA program does not have enough CHC partners to train all students in a single site for the entire clinical experience. Future solutions include improving state legislation to untether the PA from a specific physician and allowing the PA to practice at the top of their education, experience, and training. Additional innovations expanding the PA role include allowed eligibility for direct payment from public and private insurers and for all states and territories of the U.S. to create separate majority PA boards to regulate PAs. And although there is much work to be done, ATSU-ASHS’s PA program is moving the dial in the right direction.

References

1.         Nielsen, M, D’Agostino, D, Gregory, P. Addressing rural health challenges head on. Mo Med.

2017;114(5):363-366. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6140198/

2.         American Academy of Physician Assistants. PAs in Rural locations ready to meet primary care needs. Published June 12, 2018. Accessed July 13, 2021. https://www.aapa.org/news-    central/2018/06/pas-rural-locations-ready-meet-primary-needs/

3.         Skinner, BA, Douglas, SO, Auerbach, DI, Buerhaus, PI. Implications of an aging rural physician workforce. N Engl J Med. 2019;38(4):299-301. DOI: 10.1056/NEJMp1900808

4.         Jolly, LE. Healthcare access barriers in rural America. Kentucky Journal of Undergraduate             Scholarship. 2019;3(1):1-21. Accessed July 13, 2021.

https://encompass.eku.edu/kjus/vol3/iss1/8/

5.         American Academy of Physician Assistants. 2021 AAPA salary report: Summary of national findings. Published May 2020. Accessed July 15, 2021. https://www.aapa.org/shop/salary-

report/summary-of-national-findings/

6.         U.S. Department of Labor, Bureau of Labor Statistics.  Physician assistants.Occupational Outlook

Handbook. Accessed July 6, 2021. https://www.bls.gov/ooh/healthcare/physician-

assistants.htm

7.         American Academy of Physician Assistants. State laws and regulations. Published 2021.

Accessed August 6, 2021. https://www.aapa.org/advocacy-central/state-advocacy/state-laws-

and-regulations/

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