BACKGROUND: Physician assistants (PAs) are licensed to practice with physician supervision. PAs do not specialize or subspecialize as part of their formal standard training; consequently, their license is not limited to a specific specialty. As such, PAs can, and do, change their practice settings at will. Some researchers have projected plans for the future use of the pediatric PA workforce. However, the information on which those projections have been based is limited.
OBJECTIVE: To provide information regarding the current status of pediatric PAs and to inform future workforce deliberations, we studied their current distribution and scope of practice.
METHODS: Data from the American Association of Physician Assistants and the US Census Bureau were used to map the per-capita national distribution of pediatric PAs. We conducted a mail survey of a random sample of 350 PAs working in general pediatrics and 300 working in pediatric subspecialties.
RESULTS: Most states have <50 pediatric PAs, and there is significant variation in their distribution across the nation. The overall survey response rate was 83.5%; 82% (n = 359) were female. More than half of the respondents (57% [n = 247]) reported that they currently are working in pediatric primary care, mostly in private-practice settings.
CONCLUSIONS: PAs can, and do, play an important role in the care of children in the United States. However, the impact of that role is limited by the relative scarcity of PAs currently engaged in pediatric practice.
WHAT'S KNOWN ON THIS SUBJECT:
Physician assistants (PAs) are licensed to practice medicine with physician supervision. As of 2009, there were ∼72 000 PAs in clinical practice in the United States.
WHAT THIS STUDY ADDS:
The authors provide information regarding the current distribution and scope of practice of PAs who work within the field of pediatrics.
Physician assistants (PAs) are licensed to practice medicine with physician supervision. Formal training is conducted in educational programs accredited by the Accreditation Review Commission on Education for the Physician Assistant. PA training lasts a median of 26 months and is inclusive of >2000 hours of supervised clinical practice.1
In 2010, there were 142 accredited PA programs in the United States.2 Patterns of PA distribution overall have been closely linked to physician distribution.1 PAs do not specialize as part of their formal standard training; consequently, their license is not limited to a specific specialty. As such, PAs can, and do, change their practice settings as they or market conditions dictate. Over time, more PA programs have offered optional opportunities for advanced postgraduate training and specialization, with at least 55 specialty-specific programs now in existence nationwide.3
As of 2009, there were ∼72 000 PAs in clinical practice in the United States.4 PAs practice in a diverse array of settings and in all medical and surgical specialties as part of physician-PA teams. According to the 2009 American Academy of Physician Assistants (AAPA) census, 36% of PAs practice in adult primary care, 22% in surgery, 11% in internal medicine subspecialties, and 10% in emergency medicine.4 A comparatively smaller number of PAs (4%) currently practice in pediatrics.4 Despite the small numbers of PAs in pediatrics, there has been a significant increase in interest regarding the use of PAs in a variety of clinical settings.5,6 We conducted a study to describe the current distribution of pediatric PAs in the United States and their scope of practice.
Distribution of Pediatric PAs
We used the AAPA roster of pediatric PAs by state to estimate PA counts. The list was obtained through Medical Marketing Service, Inc (MMA) and contained the complete list of the 2144 self-identified pediatric PAs as of June 12, 2009.
Child population data were derived from 2008 US Census Bureau estimates. We calculated the state PA-to-child population ratio as the number of PAs divided by the state population aged 0 to 17 years, multiplied by 100 000.
Scope of Practice of Pediatric PAs
We surveyed a random sample of PAs working in the field of pediatrics. The sample was obtained through MMS. MMS maintains a list of PAs that is updated twice monthly from the AAPA. The list contains information on >70 000 AAPA member and nonmember PAs in the United States. Specialty and subspecialty data are self-reported. The final sample contained 350 PAs working in general pediatrics and 300 PAs working in a pediatric subspecialty. PAs working in pediatric surgery were excluded.
We developed a structured questionnaire to be administered by mail. The survey contained 13 fixed-choice items and 1 open-ended item.
The first mailing was sent via US Postal Service Priority Mail in September 2009. The survey packet contained a personalized cover letter signed by Dr Freed and collaborator Mr Moote (chief PA at the University of Michigan); the instrument; a business reply mail envelope; and a $5 bill as an incentive. Two additional mailings were sent to nonrespondents in October and November 2009.
Frequency distributions were calculated for all survey items. On the basis of their response to a screening question, PAs were grouped into 2 categories: primary care and specialty care, which includes pediatric emergency care. Bivariate analyses were conducted on these 2 groups, and χ2 statistics were used to determine the level of association between the outcome variables and the predictor variables. We report the statistically significant results from these comparisons. The study was approved by the University of Michigan Medical Institutional Review Board.
Distribution of Pediatric PAs
The per-capita distribution of pediatric PAs is shown in Fig 1. The greatest concentration per capita was along the Eastern Seaboard and in a contiguous 4-state area in the West. Thirty-seven states and the District of Columbia had <50 total pediatric PAs practicing within their borders.
Scope of Practice of Pediatric PAs
Of 650 survey packets mailed, 523 PAs returned the survey and 26 surveys were undeliverable (overall response rate: 83.5%). Seventy-six (15%) of those who returned the survey were ineligible, because they were no longer working in the field of pediatrics. A total of 438 surveys were left for analysis.
Eighty-two percent (n = 359) of the respondents were female. The majority of respondents worked in urban areas with a population center of at least 50 000 residents (98% [n = 427]).
More than half of the respondents (57% [n = 247]) reported that they were working in pediatric primary care (Table 1).
The majority of PAs who responded to the survey (63% [n = 276]) were not caring for any patients in a hospital setting. Approximately one-fifth of PA respondents cared for patients on hospital wards (22% [n = 95]) and in the NICU (20% [n = 86]). Many significant differences were seen between PAs who worked in primary care and those who worked in subspecialty care (Table 2).
Relationship With Supervising Physician
Ninety-five percent (n = 416) of the PAs reported that they practiced in the same facility as their supervising physician. Of the 5% (n = 22) who indicated that their supervising physician did not practice in the same facility, 90% (n = 18) reported that they were supervised by telephone. The vast majority (88%) reported daily contact with their supervising physician, 10% reported weekly contact, and 2% reported monthly contact.
The majority of PA respondents indicated that they often or sometimes conduct assessment and diagnosis (96% [n = 406]), educate patients (94% [n = 396]), and develop and manage treatment plans (98% [n = 413]) (Table 3).
Career Plans and Demographics
Approximately three-quarters of PA respondents (74% [n = 324]) were employed full-time. Forty-nine percent (n = 213) worked 40 to <60 hours/week, whereas 27% (n = 117) reported that they worked between 30 and <40 hours/week.
Among the most important findings from our study is that in 2009, ∼3% of the entire PA workforce was employed in nonsurgical pediatric primary or subspecialty care and that in most states there were <50 pediatric PAs in practice. This result is significant in that some leaders have posited that PAs will play a substantive role in addressing pediatric subspecialty workforce shortages.5,–,7 The relative paucity of the number of PAs practicing in pediatrics suggests that a substantial impact on overall medical workforce supply in pediatrics is unlikely to occur.
Increasing the supply of pediatric PAs may be hindered by pressure for newly graduated PAs, as well as those currently in practice, to pursue careers in adult medicine, for which the perceptions of a primary-care shortage is greater, or in the surgical specialties, for which compensation is likely to be higher. The impact of the “aging of America” will be keenly felt across all aspects of health care, including the preferential deployment of personnel and resources to provide care for our aging population.8 In addition, an increasing number of PAs also are being recruited by surgical residency programs to compensate for decreased duty hours of housestaff.3
Fifty-nine percent of current PA-training programs have plans to expand their class sizes within the next 5 years.9 Although most of these new graduates will be drawn to the care of adults, these plans may represent a new opportunity to increase the number of PAs entering pediatric care.
Another important finding is that the current majority (57%) of pediatric PAs practice in primary care, mostly in private-practice settings, which is in contrast to data from the 2009 AAPA census that indicated that only 36% of PAs were working in primary care.4 Subspecialty PAs are almost evenly divided in practicing in either academic centers or community hospitals. Some have successfully been integrated into critical care and inpatient units in both of these settings.10 Those who make future projections for pediatric PAs in either primary or subspecialty care should take note of the current distribution of care provision.
It is important to remember that PAs have the professional flexibility to change the specialty, or focus within a specific specialty, of their practice. It is unknown how often PAs change specialties, although in our study 15% of respondents reported that they were no longer working in pediatrics. This professional flexibility creates an important degree of plasticity in PA deployment.
One of the possible reasons for the relative paucity of pediatric PAs may be a lack of postgraduate training programs in pediatrics. A recent review of the training programs listed by the Association for Postgraduate Physician Assistant Programs found none for pediatrics.3 We are aware of only 1 such program in the United States, and it is focused on neonatal medicine.6 The Child Health Associate Program in Colorado, which trains PAs with a focus in pediatrics, has 44% of its total 749 graduates practicing in pediatrics,11 which represents ∼10% of all pediatric PAs in the nation.
Most research on PAs in the United States has not included pediatric care provision or has not separated out the care of children from the larger adult population. Unfortunately, the reports regarding pediatric visits conducted by PAs or their economic impact often are fraught with methodologic problems. Some reports combine PAs with pediatric nurse practitioners into a general midlevel provider category,7,11,–,16 whereas others may use data sets that were not developed or powered to assess PA care provision.17 Better tracking of pediatric PAs would assist policy makers in workforce planning and projections.
PAs can, and do, play an important role in the care of children in the United States. However, the impact of that role is limited by the relative scarcity of PAs currently engaged in pediatric practice. For PAs to play a more significant role in either primary care or subspecialty care, greater numbers of them must select pediatric care over other professional opportunities.
- Accepted July 30, 2010.
- Address correspondence to Gary L. Freed, MD, MPH, University of Michigan, Child Health Evaluation and Research (CHEAR) Unit, 300 North Ingalls Building, Room 6E08, Ann Arbor, MI 48109-0456. E-mail:
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
- PA =
- physician assistant •
- AAPA =
- American Academy of Physician Assistants •
- MMS =
- Medical Marketing Service, Inc •
- PNP =
- pediatric nurse practitioner
- 2.↵Physician Assistant Education Association. PA program geographic locations. Available at: www.paeaonline.org/index.php?ht=d/sp/i/67788/pid/67788. Accessed April 22, 2010
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- 4.↵American Academy of Physician Assistants. 2009 AAPA physician assistant census national report. Available at: www.aapa.org/images/stories/Data_2009/National_Final_with_Graphics.pdf. Accessed April 23, 2010
- 5.↵American Academy of Pediatrics, Committee on Pediatric Workforce. Scope of practice issues in the delivery of pediatric health care. Pediatrics. 2003;111(2):426–435
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- Copyright © 2010 by the American Academy of Pediatrics